I was enjoying lunch with a friend a few weeks ago when he took a swig of his soda, read the nutrition facts and said in a puzzled manner “37 grams of carbohydrates. That seems like a lot. What exactly are carbs?”

“The enemy,” I quipped.

Now, this was merely a split-second, subconscious response that needs clarification. So by all means, I beg your pardon. Carbohydrates are not necessarily our adversary, and can in fact be our friend, but only if we understand the difference between “good carbs” and “bad carbs.” Let me explain.

Carbohydrates are essentially sugars or starches that provide energy for our bodies. Sounds good right? Not so fast! “Bad carbs” are high in glucose and, when consumed, cause a quick spike in our blood-sugar levels. This causes our pancreas to pump out insulin to deal with the excess blood sugar. The insulin then disperses the glucose and our blood sugar levels fall, causing us to be hungry again! I’m sure you’ve experienced this without even knowing it. Remember last week when you ripped through that bag of Cool Ranch Doritos, like Sasquatch attacking Jack Link’s Beef Jerky? Or how about when you had the urge to eat that Rocky Road ice cream with a shovel? Excuse my hyperbole, but these cravings are a result of the quick rise and fall of our sugar levels. Bad carbohydrates are very high in sugar and white flour and include: candy, baked foods, ice cream, white pasta, breads, and sodas. These carbohydrates, while tasty, can often lead to obesity, heart disease and diabetes.

Good carbohydrates, however have a low glycemic index and are generally high in fiber, and rich in vitamins, minerals, and nutrients. These carbs raise our blood glucose levels in a much slower and sustained manner, avoiding the spike that leads to more cravings. These carbs, especially those high in fiber, are essential to our everyday diet. They supply our bodies with energy and help to lower our cholesterol. We want our bodies to take energy from carbs because if no carbs are consumed, our protein intake will be unnecessarily used for energy, diminishing their benefits for muscle growth. Good carbohydrates include: fruits, vegetables, sweet potatoes, brown rice, beans, nuts, whole grain cereals and oat meal.

Now you may still crave that pint of ice cream, but it will be less intense and instead of grabbing the shovel, you’ll just take out a spoon. Consciously replace “bad carbs” with “good carbs,” and you’ll decrease your cravings and feel more energy. Oh, and those jeans will fit again!

About Our Celebrity Blogger. Joseph Pepe, Jr. serves as the Director of Project Development for Planet Fitness.  He oversees the Personal Training and Nutrition Department for 14 locations throughout CT.  He is also the Managing Director for the Lose It! Weight Loss System (www.loseitweightloss.com).  Joe received his B.A. in Economics from Wesleyan University. And since he’s our health and fitness guru, lets give him a plug as a athlete in his younger years as an All-NESCAC and Academic All-NESCAC Football Selection at Wesleyan. Go Cardinals!!

Intelecare's Alex Sicre

When Intelecare decided to enter the social media space with its first blog entry in 2007, I was less than bullish on the idea.  I suppose it was just a fear of the unknown – a suspicion of the efficacy or usefulness of something I just didn’t understand.  But nearly 3 years later, Intelecare boasts a presence on Facebook and Twitter, is a biscuit away from launching various consumer-centric videos and a weekly Podcast (also available on YouTube) and, today, a resuscitated blog in honor of the man who started it all – Alex Sicre.

Alex was a thoughtful, poignant writer.  He loved research and, indeed, spreading the good word about all things he believed in.  His commitment to the idea that educating patients and caregivers through organic, grassroots approaches would result in better, more viable outcomes, was spot-on.  In the time since Alex’s passing in November 2008, he has left us a legacy of kindness and thought-provoking work as we continue the battle to increase medication adherence.

In the past year, Intelecare has broadened its member base and increased its work with managed care organizations, pharmacies and pharmaceutical companies.  Launched a completely overhauled user experience and continued to increase the number of patients using the Intelecare system – all during this volatile economic climate.  In that same time frame we lost touch with that grassroots philosophy that Alex championed to educate a community about the negative effects of non-adherence.  That ends today.

Alex’s work at Intelecare immersed him in the issues of non-compliance, but even he struggled with adherence to his medication regimen.  If medication adherence was difficult for someone like Alex, imagine how trying it can be for patients and caregivers whose busy lives pull them in multiple directions without a direct understanding of the ramifications of non-adherence?  Make no mistake about it, non-adherence is America’s biggest drug problem.

I am reminded of the statistics everyday:

• 1 out of every 2 people are non-compliant
• $300 billion in costs to the healthcare system with far reaching health and socio-economic implications
• $47 billion in hospitalization costs directly attributed to non-adherence

The statistics are daunting, but we can change them.  We can increase adherence and persistency.  At Intelecare, we believe our communications hub permits results based on a preference-based reminder.  Our approach to communications is paradigm-shifting that includes reminders but provides education, rewards and, ultimately, home delivery of medications with a click of a button.

Please join the entire Intelecare family in making this goal of increasing medication adherence a reality today.

I do not use Wikipedia regularly, however I find increasingly useful for trivial information, such as who is Lonelygirl15, since I missed all the YouTube ballyhoo.

I think UGC (user generated content) is fantastic, however I do not think it is always an authoritative source. With that in mind, I looked up the my favorite terms: medication adherence, medication non-adherence, medication compliance and medication non-compliance. The only listing was Compliance (Medicine).

From the Wikipedia entry:

“Compliance (or Adherence) is a medical term that is used to indicate a patient’s correct following of medical advice. Most commonly it is a patient taking medication (drug compliance), but may also apply to use of surgical appliances such as compression stockings, chronic wound care, self-directed physiotherapy exercises, or attending counselling or other courses of therapy.

Patients may not accurately report back to healthcare workers because fear of possible embarrassment, being chastised, or seeming to be ungrateful for a doctor’s care.

Causes for poor compliance include:
• Forgetfulness
• Prescription not collected or not dispensed
• Purpose of treatment not clear
• Perceived lack of effect
• Real or perceived side-effects
• Instructions for administration not clear
• Physical difficulty in complying (e.g. opening medicine containers, handling small tablets, swallowing difficulties, travel to place of treatment)
• Unattractive formulation, such as unpleasant taste
• Complicated regimen
• Cost of drugs”

The listing goes on to discuss “Adherence: An estimated half of those for whom medicines are prescribed do not take them in the recommended way. Until recently this was termed “non-compliance”, and was sometimes regarded as a manifestation of irrational behavior or willful failure to observe instructions, although forgetfulness is probably a more common reason. But today health care professionals prefer to talk about “adherence” to a regimen rather than “compliance”….”

And “Drug Compliance: It is estimated that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations….”

And “Concordance: Concordance is a current UK NHS initiative to involve the patient in the treatment process and so improve compliance….”

Overall it is a great listing. Wikipedia (rather the authors & editors) address the causes, the percentage of patients who are non-adherent, and the differences between adherence and compliance and concordance.

I guess I will have to live the listing title: Compliance (Medicine).

Recent Guidline research published by MedAdNews found that 6 in 10 Americans are now non-adherent to their medications. Now lets talk about what this really means in cost for diabetes patients and the strain medication non-adherence has on the US healthcare system.

The June 2005 issue of Medical Care, a journal by the American Public Health Association, published a study demonstrating that Diabetes patients who are highly compliant with their treatment programs have a 13% hospitalization risk for a diabetes-related problem, but patients with low compliance have more than twice the risk at 30%.

The same study stated the combined drug and medical costs for the most compliant patients average $4,570, which is almost 50 percent below the $8,867 cost for the least compliant group.

A recent report from the CDC states that diabetes rates are rising in the US. More than 23 million Americans have diabetes, with about 1.6 million new cases diagnosed among adults last year.

So currently, according to all these estimates, 13.8 M diabetics are non-adherent to their medication regimes, and cost the healthcare system $122 BILLION. With proper medication adherence, this figure can be reduced in half.

And this number is only going to go up, with almost 1M non-adherent diabetes added each year at a cost of $8.8 Billion.

And this is for one chronic disease.

There are several factors related to why patients are non-adherent to their medications and I do not mean to beat up on diabetics, but I just wanted to illustrate the real costs associated with not taking medications properly.

Smells like Conference season, considering the Health 2.0 Conference launches tonight, and there are four more events on the horizon in the next two weeks!

While the results are not groundbreaking, they further reinforce the disconnect between patients and doctors regarding medication adherence.

1,017 responded to Zoomerang’s invite to participate in InfoMedics, Inc.’s 2008 “Following Doctor’s Orders: Patient Prescription Behaviors” survey. All had taken prescription medications, with no particular demographic breakdown.

Survey Says (my comments are in BOLD):

34% do not always fill a new prescription from their doctors; another 5 percent said they never fill those prescriptions.
The latest poll I saw was around 30% – getting higher, wonder if economy affected this answer? Probably too early.

46% said there is a chance they would not tell their doctor if they stopped taking a medication or decided not to fill a prescription. This is bad. Obviously if a doctor doesn’t know you are not taking your medication, they will not know how to effectively treat your ailment. Good thing there is blood work to determine medication levels.

67% forget to take their medication at times. Last figure I have from 2007 is 87% – so that is a pretty steep decline.

9% said they would keep taking a medication if they started feeling worse. Not a very engaged population number.

34% sometimes, often or always stop taking medication if they feel better. This number sounds low.

46% are careless at times when taking medications. Sound about right.

32% are always motivated to take a newly prescribed medication.Better than 30%!

When asked for multiple responses about where they go for medication information, 51 percent of respondents said they look to the Internet for this information; 49 percent said they ask their pharmacists and 37 said they ask their doctors.
This follows Manhattan Research’s Cybercitizen® Health v8.0 report that stated 53% of patients prefer to look online for health information.

Overall this survey is pretty representative of the current research, with a good indicator that adherence rates are not going above 50%. I am looking forward to seeing the whole survey when it is published.

From Reuter’s Health, a report on Sex Bias in Control of Cancer Pain:

“How well pain is managed in people with cancer apparently differs between men and women, new research hints. Dr. Kristine A. Donovan, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, and colleagues examined pain severity and the adequacy of pain management in 131 cancer patients newly referred to a multidisciplinary cancer pain clinic.” Full Story

From LifeScript, a study that shows 1 in 5 Diabetics do not take their medication as prescribed. “Too many diabetics are neglecting to take life-saving prescription medicines regularly, one study warned. Published in the Archives of Internal Medicine, the study estimated that 21% of diabetics fail to adhere to their prescription schedule.” Full Story

Allan Showalter, MD from AlignMap discusses the Implications Of The Redundant Patient Compliance Review. I like to post abstracts and some compliance reviews, but his blog posts are always more insightful, biting and from an MD’s perspective. Full Story

And lastly, from the International Journal of STD and AIDS: Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil. Full Story.

No one has a robust, web-based proprietary medical messaging platform that sends patient and caregiver created reminders via email, text and voice messaging. No one offers our hosted and enterprise solutions to industry. No one has 3.2M users and sends out 4M reminders daily. No one has a pro bono program that gives away their technology. No one is developing the next generation in Adherence 2.0 applications like we are.

Since that call, a handful of competitors have emerged offering similar products. In fact, one such competitor even used the same phrasing we have used on our website for two years to describe the services they offer and the industries they serve.

Competitors aside, Intelecare is still the gold standard – no matter how many other companies come into the space.

Even though our competitors charge for their reminders, we still offer a free service to patients and caregivers to ensure that they are helped with the #1 cause of medical non-adherence, forgetfulness. We still integrate our reminder platform into any existing web portal – both as an out of the box hosted solution and as a fully customized enterprise solution. We still offer our hosted email reminder platform pro-bono to non-profits that specialize in chronic disease states.

That being said, I found a press release from Adheris today announcing a study which results “showed that patients new to antidepressant treatment and those who had restarted therapy after a lapse of 6 or more months were twice as likely to discontinue therapy in the first 30 days of treatment versus patients previously dispensed an antidepressant.”

This is significant because the first 30 days of therapy are integral to a patient continuing their therapy. “The practical implications of this study are that while all patients lapsed at an alarming rate over time, increased patient follow-up and education within the first 30 days of therapy in newly treated and lapsed patients restarting therapy are critical to help improve adherence and patient outcomes.”

Adheris is a fantastic company that has been in the space for over 9 years. They are focused on increasing patient adherence and education at the pharmacy level. Several times I have been asked to compare our services to theirs – however it is apples and oranges. We are both trying to get to the same goal – increasing patient medication adherence – we just have two distinct ways of doing it.

Medication non-adherence costs the US $300 BILLION annually in unnecessary health care costs and lost revenue. 1 in 2 patients does not take their medications as directed with 84% of them citing forgetfulness as the reason.

I think this market is big enough for a few players with different ideas of how to end this pandemic. It not only takes reminders, but education and lower drug costs to help eradicate the problem which affects us all in one way or another.

Background:
Medication-related problems that lead to hospitalization have been the subject of many studies, many of which were limited to 1 hospital or lacked patient follow-up. Furthermore, little information exists on potential risk factors associated with preventable medication-related hospitalizations.

Methods:
A prospective multicenter study was conducted to determine the frequency and patient outcomes of medication-related hospital admissions. A case-control design was used to determine risk factors for potentially preventable admissions. All unplanned admissions in 21 hospitals were assessed during 40 days.

Controls were patients admitted for elective surgery. Cases and controls were followed up until hospital discharge. The frequency of medication-related hospital admissions, potential preventability, and outcomes were assessed. For potentially preventable medication-related admissions, risk factors were identified in the case-control study.

Results:
Almost 13 000 unplanned admissions were screened, of which 714 (5.6%) were medication related. Almost half (46.5%) of these admissions were potentially preventable, resulting in 332 case patients matched with 332 controls. Outcomes were favorable in most patients.

The main determinants of preventable medication-related hospital admissions were impaired cognition (odds ratio, 11.9; 95% confidence interval, 3.9-36.3), 4 or more comorbidities (8.1; 3.1-21.7), dependent living situation (3.0; 1.4-6.5), impaired renal function (2.6; 1.6-4.2), nonadherence to medication regimen (2.3; 1.4-3.8), and polypharmacy (2.7; 1.6-4.4).

Conclusions:
Adverse drug events are an important cause of hospitalizations, and almost half are potentially preventable. The identified risk factors provide a starting point for preventing medication-related hospital admissions.

Enjoy!

ONE:  Testing the psychometric properties of the Medication Adherence Scale in patients with heart failure

OBJECTIVE:
Many factors may contribute to medication nonadherence in heart failure (HF), but no standard measure exists to evaluate factors associated with nonadherence. To fill this gap, we developed the Medication Adherence Scale (MAS) and tested its reliability and validity in patients with HF.

METHOD:
Questionnaire data were collected from 100 patients with HF at baseline using the MAS, and objective adherence data were collected for 3 consecutive months using the Medication Event Monitoring System.

RESULTS:
Principal component analysis yielded three factors that explained 63% of the variance in medication adherence: knowledge, attitudes, and barriers to medication adherence. Cronbach’s alphas for these subscales ranged from .75 to .94, which supported their internal consistency. The Spearman rho correlation coefficients between the Medication Event Monitoring System and Knowledge, Attitudes, and Barriers scores were .25 to .31 (P < .05), demonstrating support for construct validity.

CONCLUSION:
These results support the reliability and validity of the MAS as a measure of knowledge, attitudes, and barriers of medication adherence.
TWO: Revision and validation of the medication adherence self-efficacy scale (MASES) in hypertensive African Americans

Study purpose was to revise and examine the validity of the Medication Adherence Self-Efficacy Scale (MASES) in an independent sample of 168 hypertensive African Americans: mean age 54 years (SD = 12.36); 86% female; 76% high school education or greater. Participants provided demographic information; completed the MASES, self-report and electronic measures of medication adherence at baseline and three months.

Confirmatory (CFA), exploratory (EFA) factor analyses, and classical test theory (CTT) analyses suggested that MASES is unidimensional and internally reliable. Item response theory (IRT) analyses led to a revised 13-item version of the scale: MASES-R. EFA, CTT, and IRT results provide a foundation of support for MASES-R reliability and validity for African Americans with hypertension. Research examining MASES-R psychometric properties in other ethnic groups will improve generalizability of findings and utility of the scale across groups. The MASES-R is brief, quick to administer, and can capture useful data on adherence self-efficacy.

THREE: Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis.

Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil.

The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.

FOUR:  Evidence-based Assessment of Adherence to Medical Treatments in Pediatric Psychology

Objectives:
Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown.

Methods:
This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors.

Results:
Ten measures met the “well-established” evidence-based (EBA) criteria.

Conclusions:
Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the “real time” behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

Why aren’t you doing it? The costs are reduced for 90 day supplies. It makes perfect sense to me, since I am on two maintenance medications, yet I still have not done it – why? I do not really know. I printed out the form, and then it sat on my desk for a week. I think I took it home, then it was put in a drawer and lost it. We have since changed health plans, so maybe I will look into it again.

Enjoy the Q and A:

Can you give a brief explanation of Express Scripts’ Center for Cost-Effective Consumerism?

The center brings together leading experts in behavioral economics to gain an advanced understanding of human behavior applied to health care. The center uses this information to help bring about positive health behavior change one consumer at a time. Right now, we’re focused on procrastination as one major obstacle to better behavior.

One of the center’s recent studies found patients were more likely to take medications as directed when they received those medications through the mail. Can you discuss these findings?

The study found that medication compliance was about 8 percentage points higher at home delivery than retail in key therapy classes: diabetes, high cholesterol and high blood pressure. The study involved more than 70,000 patients followed for nine months, and the design was such that we are confident that the difference in therapy adherence was due directly to home delivery.

Do you know any reasons why patients receiving drugs through mail order are more compliant?

There are at least two issues. First, it’s clear that some of the noncompliance is due to procrastination when it comes to getting refills. This leads to gaps in compliance because patients wind up not having their medications. Because home delivery offers 90-day supplies, there are fewer refills needed and thus fewer gaps.

Second, our data show that patients in home delivery are far more engaged; they call us more often, log in to our website more often and increasingly view us as a trusted partner. This helps us communicate more effectively with them about their care.

Why don’t more patients choose mail order?

Based on our work with the center’s advisory board, we think it’s more about procrastination than an active decision not to use home delivery.

In the past, moving to home delivery meant filling out forms, calling the doctor for a new prescription written for 90-day fills, etc. Express Scripts has new programs that take almost all of that work off patients’ shoulders, so we expect a lot more of them to take advantage of home delivery going forward.

What should employers and other health insurer purchasers do if they want to encourage their employees or members to use mail order?

Clearly, financial incentives are not enough to drive members to home delivery. In addition to making sure patients save money on their co-payments at mail, employers and insurers should work with a PBM partner that can address the issue of procrastination and communicate effectively with patients.