Jack E. Fincham
INTRODUCTION
Many roles are assigned to health professionals; the daily fulfillment of these roles in an exemplary fashion is the hallmark of health professional practice and delivery of health care to patients in the United States. Patients are thus well served, and fellow health professionals share knowledge and expertise specific to their profession. Despite this, many problems remain in the U.S. health care system; there are 46 million uninsured individuals in the United States, representing between 16% and 17% of the population. Many more in our midst are underinsured. They may have coverage after a fashion, but the deductibles, co-pays, and monthly payments for insurance create an economic dilemma for individuals each time they seek care or pay premiums. According to the U.S. Centers for Medicare and Medicaid Services, National Health Expenditure data, well over $2.2 trillion was spent on health care in the United States during 2007 amounting to $7,400 per person, some of it no doubt unnecessarily so.1
The use of medications in the health care system provides enormous help to many; lives are saved or enhanced, and lifespans are lengthened. Many other uses of medications lead to significant side effects, worsening states of health, and premature deaths. So, how to separate these disparate pictures of drug use outcomes? You, within your practices and within your networks in the health workplace, can help to promote the former and diminish the latter. The authors of the chapters in this book have written sterling chapters that can empower you to positively influence medication use.
DRUG USE IN THE HEALTH CARE SYSTEM
Spending on drugs, as a percentage of what was spent on health care in total, increased from 5.8% to 8.5% from 2005 to 2006.2 This amounts to a percentage increase of 47% in 1 year. Drivers for this significant increase include increasing available technologies, increasing numbers of patients and prescriptions per patient, and an increasing number of seniors taking advantage of the Medicare Part D Drug Benefit.2 Generic drug use accounts for over 50% of prescriptions filled in the United States, but, as a percentage of expenditures on drugs in total, remains less than 30%. Brand-name drug purchases fuel the increase in spending on drugs as evidenced by the 2006 data.2
There are significant numbers of medications used daily in the United States. Over one decade (from 1997 to 2007) prescriptions purchased zoomed from 2.2 billion to 3.8 billion.3 The average number of prescriptions per capita in the United States rose from 8.9 in 1997 to 12.6 in 2007.3 Problems occurring with the use of drugs can include:
• Medication errors
• Suboptimal drug, dose, regimen, dosage form, and duration of use
• Unnecessary drug therapy
• Therapeutic duplication
• Drug–drug, drug–disease, drug–food, or drug–nutrient interactions
• Drug allergies
• Adverse drug effects, some of which are preventable
Clinicians are often called upon to identify, resolve, and prevent problems that occur due to undertreatment, overtreatment, or inappropriate treatment. Individuals can purchase medications through numerous outlets. Over-the-counter (OTC) medications can be purchased in pharmacies, supermarkets, convenience stores, via the Internet, and through any number of additional outlets. OTCs are widely used by all age groups. Prescription medications can be purchased through traditional channels (community chain and independent pharmacies), from mail-order pharmacies, through the Internet, from physicians, from health care institutions, and elsewhere. Herbal remedies are marketed and sold in numerous outlets. The monitoring of the positive and negative outcomes of the use of these drugs, both prescription and OTC, can be disjointed and incomplete. Clinicians and health professions students need to take ownership of these problems and improve patient outcomes resulting from drug use.
It is important to realize that, although clinicians are the gatekeepers for patients to obtain prescription drugs, patients can obtain prescription medications from numerous sources. Patients may also borrow from friends, relatives, or even casual acquaintances. In addition, patients obtain OTC medications from physicians through prescriptions, on advice from pharmacists and other health professionals, through self-selection, or through the recommendations of friends or acquaintances. Through all of this, it must be recognized that there are both formal (structural) and informal (word-of-mouth) components at play. Health professionals may or may not be consulted regarding the use of medications, and in some cases are unaware of the drugs patients are taking. In addition, herbal remedies or health supplements may be taken without the knowledge or input of a health professional.
External variables may greatly influence patients and their drug-taking behaviors. Coverage for prescribed drugs allows those with coverage to obtain medications with varying cost sharing requirements. However, many do not have insurance coverage for drugs or other health-related needs. With the advent of Medicare Part D coverage for outpatient prescription medications, we have seen more of the elderly with access to needed therapy—more than ever before.4
Self-Medication
Self-medication can be broadly defined as a decision made by a patient to consume a drug with or without the approval or direction of a health professional. The self-medication activities of patients have increased dramatically in the late 20th and early 21st centuries. Many factors affecting patients have continued to fuel this increase in self-medication. There are ever increasing ways to purchase OTC medications. There have been many prescription items switched to OTC classification in the last 50 years, which is dramatically and significantly fueling the rapid expansion of OTC drug usage. In addition, patients are increasingly becoming comfortable with self-diagnosing and self-selection of OTC remedies. In many studies,5 self-medication with nonprescribed therapies exceeds the use of prescription medications in the patient groups assessed.
Patients’ use of self-selected products has the potential to provide enormous benefits.6 Through the rational use of drugs, patients may avoid more costly therapies or expenditures for other professional services. Self-limiting conditions, and even some chronic health conditions (e.g., allergies and dermatologic conditions), if appropriately treated through patient self-medication, allow the patient to have a degree of autonomy in health care decisions.
Compliance Issues
Patient noncompliance with prescription regimens is one of the most understated problems in the health care system. The effects of noncompliance have enormous ramifications for patients, caregivers, and health professionals. Noncompliance is a multifaceted problem with a need for interprofessional, multidisciplinary solutions. Interventions that are organizational (how clinics are structured), educational (patient counseling, supportive approach), and behavioral (impacting health beliefs and expectations) are necessary. Noncompliance leads to lack of control of hypertension and a high discrepancy in how patients respond to therapies.7 Helping to identify psychosocial interventions, which engage patients to self-manage their therapies, has proven efficacy.7 Acknowledging the barriers that people perceive in complying helps to identify how to assist patients to overcome these distracters.7Compliant behavior can be enhanced through your actions with the patients for whom you provide care. Many times what is necessary is referral to specific clinicians for individualized treatment and monitoring to enhance compliance. The case histories provided in this text will allow you to follow what others have done in similar situations to optimally help patients succeed in improving compliance rates and subsequent positive health outcomes.
Drug Use by the Elderly
Various components of drug use in the elderly are worth noting. Problems with health literacy (i.e., the understanding of medical terminology and directions from providers) are more common among the elderly.8 The burgeoning population of the elderly, coupled with their lack of health literacy, means that this issue will become even more problematic in the future.9
Over the next decade, seniors will spend $1.8 trillion on prescription medications. Medicare proposals to provide a drug benefit for seniors have been suggested to cost $400 billion over a 10-year period. Thus, the most elaborate of the current drug programs will pay only 22% of seniors’ drug costs. Enhanced use of pharmacoeconomic tenets to select appropriate therapy, while considering cost and therapeutic benefits for seniors and others, will become even more crucial for clinicians in the future.
Unnecessary drug therapy and over medication are problems with drug use in the elderly. A joint effort by health professionals working together is the best approach to aiding seniors in achieving optimal drug therapy. Evaluation of all medications taken by seniors at each patient visit can help prevent polypharmacy from occurring.10
IMPACTING THE PROBLEMS OF DRUG USE
Medication Errors
There is more glaring issue in medication use and monitoring than the need to reduce medication errors. Untold morbidity and mortality occur due to the many errors occurring in medication use. Studies have shown that reconciling the medications that patients take, with coordination by various caregivers providing care, can help reduce medication errors in patient populations.11 Current changes in how drugs are prescribed, such as electronic prescribing, barcode identification of patients, and electronic medication records, can all help reduce medication errors.12,13 As these technologies are increasingly used, the benefits will expand.
The incorporation of three key interventions (computerized physician order entry [CPOE], additional staffing, and bar coding) have been shown in an institutional setting to help reduce medication errors.13Being able to track drug ordering, dispensing, and administration electronically has been shown to be cost effective in the long run.14 Nurses and office staff have been proven as a valuable resource for reporting prescribing errors, especially with ongoing reminders to scrutinize orders.15
The Epidemic of Prescribed Drug Abuse
According to data from the U.S. National Institute on Drug Abuse, in 2006, “approximately 7 million persons were current users of psychotherapeutic drugs taken nonmedically (2.8% of the U.S. population).”16 The main classes of drugs abused that were obtained via legitimate channels through prescribers and pharmacies include:
• Pain relievers—5.2 million
• Tranquilizers—1.8 million
• Stimulants—1.2 million
• Sedatives—0.4 million15
The main source for these drugs is the family medicine cabinet. The abuse of prescription medications by adolescents is an ascending problem that all health professionals must address and work together to try to lessen in intensity.
SUMMARY
Health professionals are at a crucial juncture as we face an uncertain, yet promising future. Technological advances, including electronic prescribing, may stem the tide of medication errors and inappropriate prescribing. These technological enhancements for physician order entry (via personal data assistants or through web access to pharmacies) have been implemented to reduce drug errors. The skills and knowledge that enable effective pharmaco-therapy practice have never been more daunting among the numerous health professions. Sophisticated computer technology can further empower health professionals to play an ever increasing and effective role in helping patients and fellow health professionals to practice safe and effective medicine.
This book provides a thorough analysis of common disease states, discussion of therapies to treat these conditions, and specific advice to provide to patients to help them self-medicate when appropriate and safe to do so. The use of material in this text, which incorporates materials written by some of the finest minds in pharmacy practice and education, can enable the reader to play a crucial role in improving the drug use process for patients, providers, payers, and society. The purpose of this book is to help hone your skills, so you can make a real improvement in the therapies you provide to your patients. Current and future clinicians can rely on the information laid out here to enhance your knowledge and allow you to assist your patients with the sound advice that they expect you to provide. Use the text, case histories, and numerous examples detailed here to expand your therapeutic skills, and to help positively impact your patients in the years to come.
You can help to reverse medication related problems, improve outcomes of care both clinically and economically, and enable drug use to meet stated goals and objectives. This text provides a thorough analysis and summary of treatment options for commonly occurring diseases and the medications or alternative therapies used to successfully treat these conditions.
Abbreviations Introduced in This Chapter
|
CPOE |
Computerized physician order entry |
|
OTC |
Over-the-counter |
REFERENCES
1. U.S. Centers for Medicare and Medicaid Services, National Health Expenditures. Washington, DC, January 9, 2009. http://www.cms.hhs.gov/NationalHealthExpendData/
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3. Kaiser Family Foundation Washington, DC, September, 2008. Prescription Drug Trends, Fact Sheet (#3057-07), http://kff.org/rxdrugs/upload/3057_07.pdf.
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16. U.S. National Institute on Drug Abuse, Topics in Brief, Prescription Drug Abuse March 2008. http://www.nida.nih.gov/pdf/tib/prescription.pdf.