E-DRUG: compliance aids (3)
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Dear Dr. Halsted:
a person to contact in The Netherlands, who has used electronic
monitoring data as a management tool with patients is Dr. Arsenio Paes
<A.H.P.Paes@FAR.RUU.NL> at University of Utrecht School of Pharmacy.
Another person for you to contact regarding the role of feedback back
objective dosing history information from electronic monitoring is Dr.
Michel Burnier at the University Hospital, Dept of Medicine, in Lausanne
Switzerland. I don't have an email address for him, but his fax number is
+41-21-345-2323. He and a pharmacist colleague, Marie-Paul Schneider
have done some very nice work with in-home monitoring of dosing histories
in patients with congestive heart failure, whereby a modem link from the
patient's elecronic dosing monitor transmits dosing information on a
nightly basis, allowing phone intervention the following AM if the dsing
has not been correct. Patients with advanced CHF have a very narrow
range of tolerance for missed diuretic doses.
Another perspective on the intervention business, which is not
specifically set in the context of drug regimen compliance, but obviously
is impinging upon it, are the various telephone-care programs that have
shown remarkable improvement in outcomes and economics from frequent
phone contact with patients who have serious CHF and a past record of
high resource utilization:
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A
multidisciplinary intervention to prevent the readmission of elderly
patients with congestive heart failure. N Engl J Med 333: 1190-5, 1995.
ABSTRACT
BACKGROUND: Congestive heart failure is the most common
indication for admission to the hospital among older adults. Behavioral
factors, such as poor compliance with treatment, frequently contribute to
exacerbations of heart failure, a fact suggesting that many admissions
could be prevented.
METHODS: We conducted a prospective, randomized trial of the
effect of a nurse-directed, multidisciplinary intervention on rates of
readmission within 90 days of hospital discharge, quality of life, and
costs of care for high-risk patients 70 years of age or older who were
hospitalized with congestive heart failure. The intervention consisted
of comprehensive education of the patient and family, a prescribed diet,
social-service consultation and planning for an early discharge, a review
of medications, and intensive follow-up.
RESULTS: Survival for 90 days without readmission, the primary
outcome measure, was achieved in 91 of the 142 patients in the treatment
group, as compared with 75 of the 140 patients in the control group, who
received conventional care (P = 0.09). There were 94 readmissions in the
control group and 53 in the treatment group (risk ratio, 0.56, P =
0.02). The number of readmissions for heart failure was reduced by 56.2
percent in the treatment group (54, vs. 24 in the control group; P =
0.04), whereas the number of readmissions for other causes was reduced by
28.5 percent (40 vs. 29, P not significant). In the control group, 23
patients (16.4 percent) had more than one readmission, as compared with 9
patients (6.3 percent) in the treatment group (risk ratio, 0.39; P =
0.01). In a subgroup of 126 patients, quality-of-life scores at 90 days
improved from more than base line for patients in the treatment group (P
= 0.001). Because of the reduction in hospital admissions, the overall
cost of care was $460 less per patient in the treatment group.
CONCLUSIONS: A nurse-directed, multidisciplinary intervention can
improve quality of life and reduce hospital use and medical costs for
elderly patients with congest heart failure.
Anon. Stanford "Multifit" CHF disease management program reduces ER
visits by 52% in trial at Kaiser; medication compliance "infrastructure
is key, Stanford feels. F-D-C Reports, Washington DC, July 1, 1996, pp
13-14.
West JA, Miller NH, Parker KM, Senneca D, Ghandour G, Clark M,
Greenwald G, Heller RS, Fowler MB, DeBusk RF. A comprehensive
management system for heart failure improves clinical outcomes and
reduces medical resource utilization. Am J Cardiol 79: 58-63,
1997.
These important studies should not be overlooked, because, while they are
not specifically focussed on compliance/dose organizer gadgetry (unless
one wants to interpret the phone as a compliance aid, which is probably
not a bad idea), they are focused on real medical problems and show major
impact on outcomes and economics. Prof. Robert DeBusk at Stanford, who
developed the 'multifit' program is convinced that about two-thirds of
the improvement wrought by the pone intervention is thru its impact on
medication compliance. Definitive work to prove that assertion remains
to be done, but it is certainly the most plausible hypothesis for why the
phone intervention programs work so well.
So, my unsolicited advice to you is: don't make the same mistake that
Brian Haynes did in that foolishly myopic review he did for The Lancet
about a year ago, which is to ignore the phone-intervention work.
One other illustration of the vallue of a less intensive phone
intervention program is the work of John Wasson at Dartmouth:
Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch
HG. Telephone care as a substitute for routine clinical follow-up. JAMA
267: 1788-93, 1992.
A nearly 30% reduction in resource utilization occurred when
patients were seen at semi-annual intervals with 3
physician-initiated phone calls were substituted for the quarterly
visit.
I hope this is helpful.
John Urquhart MD
a recent review you might be interested to look at is:
Urquhart J. The electronic medication event monitor
lessons for pharmacotherapy. Clin Pharmacokinet 32: 345-356, 1997.
It covers the phone care programs in the context of compliance monitoring
and what one can do with the resulting data.
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