The report, authored by Richard Levy, Ph.D., Robert C. Like M.D., M.S., and Harry S. Shabsin, Ph.D., finds disparities in access to medications through insurance programs, in the prescribing of medications and in adherence to medication regimens. The report offers recommendations for health-care planners and advocates, clinicians and health-care organizations to improve prescribing and use of medications in a diverse society.

“Since medications are a cornerstone of treatment for many diseases, addressing unequal or inappropriate medication use should be a focus for practitioners and organizations committed to the goal of eliminating health-care disparities. We hope this report raises awareness of the extent of medication disparities and will stimulate solutions to address the problem,” said Dr. Like, Professor and Director of the Center for Healthy Families and Cultural Diversity of the UMDNJ-Robert Wood Johnson Medical School.

The report points out that improving access to and use of medications in diverse groups requires policies that enable affordable, personalized therapy. Ethnic/racial background should, like other factors such as age or gender, be considered in selecting drugs and dosages, in the composition of drug formularies and preferred drug lists and in determining the scope of drug substitution policies. The report emphasizes that therapy must be tailored to individual needs and stereotyping and overgeneralization in caring for diverse populations should be avoided.

Dr. Levy, a health care consultant and former vice president of the National Pharmaceutical Council, states: “Differences in response to pharmaceuticals in minority populations indicate the importance of including diverse groups in comparative-effectiveness assessments. Failure to do so may reduce, rather than improve, the quality of care for ethnic and racial minorities”.

Key Findings from the Report

• Many studies have revealed ethnic/racial disparities in prescribing (under-prescribing, over-prescribing or mis-prescribing) for specific diseases or classes of medication, including medications for asthma, depression, psychosis, cardiovascular disease, diabetes, pain and infectious disease.
• Medication disparities can stem from a relative lack of health and drug insurance, aggressive cost containment in pharmacy benefits plans and reduced services at pharmacies in minority neighborhoods. All of these situations can limit access to medications or cause patients to reduce or discontinue therapy.
• Most state Medicaid programs utilize pharmaceutical cost containment polices which include prior authorization, generic substitution, preferred drug lists, copayments and caps. While fulfilling their intent to save drug costs, these policies may have the unintended consequences of limiting access to necessary medications. This limitation has been associated with increased utilization of medical services by minority patients.
• Suboptimal prescribing may reflect a clinician’s lack of knowledge about the patient’s culture or to the clinician’s beliefs about that culture. Clinicians who have that knowledge and who communicate well can positively affect treatment outcomes.
• Relatively low adherence in filling initial prescriptions, refilling prescriptions and taking medications according to directions has been reported in minority patients being treated for asthma, depression, psychosis, cardiovascular diseases, osteoporosis, diabetes and in receiving vaccinations. Low medication adherence in minority populations has been correlated with reduced health status.
• Much of the association between race/ethnicity and low adherence is explained by low household income, lack of insurance, poor education, low health literacy, language barriers and cultural beliefs. Low adherence may also reflect poor communication by providers, often due to lack of cultural competence training and time/resource constraints.
• Use of herbal or other folk remedies by persons from various cultural backgrounds can complicate, interact and sometimes detract from treatment with western medicines.
• Response to medications and optimal dosages may differ due to genetic or environmental factors, or diet. Ethnic differences have been consistently reported in the metabolism, effectiveness and frequency of side effects of many important drugs. Failure to account for these differences when prescribing or selecting agents for formularies or preferred drug lists may lead to suboptimal treatment and disparities.

The report is available online at http://store.nmqf.org/p-13-nmqf-e-books.aspx.

Most Americans can look into the medicine cabinet and find multiple prescription and over-the-counter (OTC) medications.While medications can help keep you healthy, they also can cause serious problems when used incorrectly. A large percentage of adults in the United States (U.S.) are taking too many medications, not taking their medications properly, or both.
In any given week, four out of every five U.S. adults will use prescription medicines, OTC drugs, or dietary supplements. And nearly one-third of all adults will take five or more different medications each day. The more medications you take, the more chance there is for those drugs to interact negatively with each other. There also is a greater risk of forgetting to take medications, taking them at the wrong time, or taking too much or too little.

Taking medications the wrong way is an extremely costly and dangerous problem. It increases the chances of severe
medical complications or even death. A recent study estimated that in one year, incorrect use of medications resulted in more than 9 million hospital admissions and more than 18 million emergency room visits.

Pharmacist’s Role

It is clear that something needs to be done about the increasing problem of medications being taken incorrectly. Finding solutions will require patients to work in cooperation with all of their healthcare providers.

The pharmacy profession is committed to bringing greater attention to this serious problem, and is working with other members of the healthcare team to come up with solutions. Your local pharmacists can serve as a valuable resource. See the box below for suggestions on how your pharmacist can help you take your medications safely.

TALK TO YOUR PHARMACIST

The more information you have, the better able you will be to use your medications correctly, prevent errors,
and protect your health. Check with your pharmacist about:
• When and how you should take your medication
• What to do if you miss a dose
• Any potential side effects
• How your medications might interact with other drugs you are taking
• How to safely dispose of unused medications

The Facts -Ways Medications Are Not Used Correctly

IMPROPER USE happens when consumers do not understand or follow directions for taking medications, and often results in serious consequences. For example, many Americans use non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin and ibuprofen for pain, and do not realize that improper use of these medications can lead to kidney failure or gastrointestinal bleeding.

OVERUSE happens when too much or the wrong strength of a medication is taken. For example, most people do not benefit from taking antibiotics for colds and other respiratory problems, but more than 23 million prescriptions a year are given to patients for these conditions. Overuse of antibiotics can lead to drug-resistant strains of bacteria and potentially life-threatening infections.

UNDERUSE happens when a prescribed medication is not taken when it should be. Skipping doses of a medication or taking the wrong medication can ultimately lead to hospitalization or other serious consequences. This is a growing problem, especially among children. The majority of medication errors reported in schools are due to children missing doses.

Reasons for the Problem

There are many factors that contribute to consumers taking their medications the wrong way, including:

INCREASING NUMBER OF MEDICATIONS.

The number of prescription and OTC medications is growing rapidly, making medication use more complicated and mistakes in use more likely. For example, shelves are becoming filled with different brands of the same drug, and many have different instructions for use. If you do not look closely at product labels, you could accidentally take too much or too little of a medication, or take the wrong medication.

MORE POWERFUL MEDICATIONS AVAILABLE OVER THE COUNTER.

More than 700 medications that formerly required a prescription are now available over the counter in pharmacies and supermarkets. While this has given you more opportunities to decide on your own medication therapy, these medications are not without risk. Even drugs like acetaminophen for headaches and pains can cause problems if not taken correctly.

The Facts
GREATER USE OF “NATURAL” PRODUCTS.

Morethan 40% of Americans have tried alternative medicines or dietary supplements, but many do not tell their healthcare providers they are taking them unless they are asked. Just because a medication is called “natural” or available without a prescription does not mean it is safe.Many individuals taking supplements and herbal medicines experience side effects or adverse reactions, especially when they are taking other medications at the same time.

RISE OF ADVERTISING DIRECTED AT CONSUMERS.

Pharmaceutical companies and retail stores are increasingly relying on direct appeals to the general public, including television, print, and Internet ads, to sell their products. An advertised drug may not be right for your particular condition or illness, leading you to take medications you don’t really need.
ELDERLY, CHILDREN AFFECTED
Adults aged 65 and older are more prone to taking medications incorrectly.They are more likely to use multiple medications, and may have declining vision, hearing, and memory that makes handling medications and interpreting instructions more difficult. Children also are vulnerable to mistakes in taking medications. Parents and caregivers administering medications can easily be confused by different instructions for use based on the child’s age, weight, and other medical conditions. One study found parents gave their children an incorrect dose of OTC fever medicine close to 50% of the time. Unintentional medication misuse can lead to patient harm and additional healthcare costs.

Canadian researchers say a single, daily pill combining five medicines could potentially cut by half the number of heart attacks and strokes in middle-aged people.

 The pill — called Polycap — is a cocktail of three blood-pressure lowering drugs, Aspirin to reduce blood clotting and a cholesterol-lowering drug. In tests involving more than 2,000 people in India, each component of the pill did what it was supposed to do.

 In addition, the Polycap was generally well tolerated. There was no evidence of increasing side effects with increasing number of active components in one pill.

 The 12-week study wasn’t designed to see whether the “polypill” actually reduced heart attacks, stroke and death. Larger numbers of people would need to be treated with a longer followup.

“The worry, of course is, would they just take this and sit in front of a TV and not exercise and gain even more weight,” Cannon, a spokesman for the American College of Cardiology, said in an interview. “This has to be done in concert with all the things we’re supposed to be doing — eating better, exercising more and losing weight.”

 The study involved 2,053 people, aged 45 to 80, without cardiovascular disease but with one risk factor for it, such as hypertension, obesity, high cholesterol, diabetes or smoking.

 The research team wanted to know: Is it possible, physically, to put five different ingredients into one pill? Would it work the same way as taking the compounds separately? Would it be tolerated? Would there be unexpected interactions when the drugs are given in a single pill?

 Overall, the Polycap lowered blood pressure, cholesterol and the clotting ability of the blood “in the same way as if I were taking the pills separately,” says Dr. Koon Teo, professor of medicine at McMaster and cardiologist at Hamilton Health Sciences. However, it lowered cholesterol slightly less than what would be achieved with taking the cholesterol reducer simvastatin alone.

 There were no excess side effects, Teo says. “So it looks like it’s safe.”

 ”We were excited because it’s a new paradigm of treatment,” he said.

 Getting patients to take multiple drugs, even after a heart attack, is difficult. Teo says the major appeal of the polypill is its simplicity. “People are more likely to take one pill, than five.”

 As well, large numbers of people with risk factors, such as high blood pressure, are untreated, Cannon says.

“If all these patients knew they could simply take their polypill, they might be more receptive to it,” he writes in The Lancet.

But the findings suggest the pill could potentially reduce cardiovascular heart disease by 62 per cent, and stroke by 48 per cent, researchers from McMaster University in Hamilton and St. John’s Medical College in Bangalore, India write in the journal, The Lancet. The study is to be presented Tuesday at the American College of Cardiology meeting in Florida.

 Heart disease is the leading cause of death worldwide.

 The study is a “first and crucial step” toward realizing the dream of combining several different drugs into one pill to treat many cardiac risk factors, says Dr. Christopher Cannon, a cardiologist at Brigham and Women’s Hospital in Boston and an associate professor of medicine at Harvard Medical School.

 ”We’re not all the way there yet. We do need a larger study to show this does in fact work for the longer term. But it’s a big step toward having a simple pill that could provide this broad cardio-protection to tens of millions of people worldwide.”

 The Polycap, which is manufactured by Cadila Pharmaceuticals in Ahmedabad, India, contains generic drugs. Cannon says each component would add up to about $17 U.S. a month.

 In an accompanying commentary, Cannon worries the availability of a “single magic bullet” for the prevention of heart disease could lead people to think popping a pill would solve all their problems.

The drug facts boxes included information about the side effects of the medications, as well as the rate that the side effects occurred in clinical trials. In addition, the drug facts boxes quantified the benefits of the medications over a placebo and older treatments. The drug facts boxes also included the year that the medications received FDA approval and alternative treatments that do not involve medication.

According to the study, about 72% of individuals who viewed drug facts boxes for the heart disease medications correctly said that the statin provides a larger benefit, compared with 9% of people who viewed the brief summaries currently used. About 70% of individuals who viewed drug facts boxes for the heartburn medications correctly said that the protein pump inhibitor provides a larger benefit, compared with 8% who viewed the brief summaries currently used, the study found.

Woloshin said that researchers have begun to design a pilot project in which FDA scientists have drafted drug facts boxes as they review new medications (Rubin, USA Today, 2/17). 

The study is available online. 

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery athttp://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. 

© 2009 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

The decline is likely the result of a continued shift towards lower-cost generic drugs and an increasing number of consumers who are looking to save money by self-medicating or simply reducing overall drug consumption.

KSA’s analysis suggests that retailers that can manage consumers’ perceptions of price — as much as price itself — are the most likely to be successful in the prescription drug category, especially in the present economy.

Wal-Mart gaining share; Target gets high advocacy and price-to-value

For example, many retailers have adopted discount and generic drugs programs. But Wal-Mart Stores Inc. has been the most successful at marketing its discount drug offering and appears to be gaining share from traditional drug chains, such as Rite Aid Corp., which consumers perceive as having higher prices.

Target Corp. also could prove an advantage in the prescription drug category. Consumers give the multiline retailer high advocacy and price-to-value scores.

Conducted in partnership with Prosper Inc., a leader in online market intelligence, the research includes more than three years’ worth of comprehensive consumer data and shows that:

– Prescription drug users are increasingly price sensitive. In January 2009, 20% of prescription drug consumers cited price as a reason for switching retailers, which is up from 16% in 2008.

– Retailers with a value orientation are winning the share war in this economy. Wal-Mart grew its customer base 9% over the past year.

– The share gains for value-based retailers come at the expense of the stores that consumers perceive as having higher prices. Rite Aid lost a disproportionate amount of market share to Wal-Mart, approximately 2% over the past year, because consumers believe it has higher prices.

– Despite the increasing importance of price perception, location remains the no. 1 reason why consumers choose a particular retailer for prescription drug purchas– Price-sensitive consumers are responding to discount prescription drugs programs. More than half (57%) of Wal-Mart pharmaceutical shoppers cited the retailer’s $4-generic-drugs program as a main reason for their choice of retailer.
Kurt Salmon Associates

http://www.kurtsalmon.comes. Walgreens and CVS continue to maintain share based primarily on convenient locations.

Looking at U.S. commercial plan claims for 2008, Wolters Kluwer Health found that prescription abandonment increased by 34 percent nationally compared to 2006 — jumping from an average of 5.15 percent in 2006 to 6.8 percent in 2008. It also found that abandonment increased as the amount of the co-pay increased, especially for new prescriptions. For example, new prescriptions with co-pays of $100 or more carry an abandonment rate of just over 20 percent; while with co-pays of $10 or under, the abandonment is only 4 percent.

“Price sensitivity is clearly a factor as consumers decide to forego certain prescriptions altogether, including some for chronic conditions,” said Mark Spiers, President & CEO, Wolters Kluwer Health, Pharma Solutions. “This disturbing trend may have serious health implications and seems poised to continue especially if the economy deteriorates further.”

Two-Thirds of Prescriptions Filled to be Generic by End of Year

The Wolters Kluwer Health analysis, known as Pharma Insight, also shows that generic medications continue to make significant gains over brands by grabbing more than 60 percent of all U.S. prescriptions filled in 2008, and an even greater percentage of the subset of drugs that are taken orally. According to the data, there were 2.4 billion prescriptions filled for generic drugs and only 1.4 billion for brand-name medications — an unprecedented spread of a billion prescriptions.

According to the data, U.S. prescriptions for generics and brands reached equilibrium in 2005 and then generics continued to build momentum each year thereafter increasing at a compound annual growth rate (CAGR) of 12 percent since 2004. Conversely, branded drugs slowed pace to a negative 6 percent CAGR for the same period.

“We’re close to the point, certainly by the end of 2009, where two-out-of-every-three prescriptions filled will be generic,” continued Spiers. “These trends are going to become even more pronounced moving forward as there are many blockbusters in major therapeutic areas like cholesterol reducers due to come off patent in the coming three years. The volume of available generics will increase, and there are very few new ‘blockbuster’ drugs in the pipeline to replace them.”

According to Spiers, many factors contribute to the steady growth of generic prescriptions in America, among the most prevalent: patient education, awareness and changing attitudes. “Patients are becoming far more comfortable with the concept of using a generic in place of a brand. This, in part, is due to patient education programs and enthusiasm forged by marketing vehicles such as $4 generic drug programs,” said Spiers.

The data also suggest that the economy is playing an enormous role in patient decision-making. As third-party insurers set higher co-pays for brands, patients are reacting by forcibly choosing generic alternatives. Spiers suggests that the economic downturn is going to further drive this demand and further spur prescription abandonment. “Increased unemployment and high numbers of newly uninsured are encouraging patients to look for ways to cut costs,” added Spiers. “Choosing a generic over a brand fits right into that mindset.”

About Wolters Kluwer Health

Wolters Kluwer Health (Philadelphia, PA) is a leading provider of information and business intelligence for students, professionals and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry. Major brands include traditional publishers of medical and drug reference tools and textbooks, such as Lippincott Williams & Wilkins and Facts & Comparisons(R); electronic information providers, such as Ovid, UpToDate(R), Medi-Span(R) and ProVation(R) Medical; and pharmaceutical information providers such as Adis International and Source(R).

Wolters Kluwer Health is a division of Wolters Kluwer, a leading global information services and publishing company. The company provides products and services for professionals in the health, tax, accounting, corporate, financial services, legal, and regulatory sectors. Wolters Kluwer had 2008 annual revenues of euro 3.4 billion ($4.9 billion), employs approximately 20,000 people worldwide, and maintains operations in over 35 countries across Europe, North America, Asia Pacific, and Latin America. Wolters Kluwer is headquartered in Amsterdam, the Netherlands. Its shares are quoted on Euronext Amsterdam (WKL) and are included in the AEX and Euronext 100 indices.

About Source

Source(R) is a leading provider of market data and analytics for pharmaceutical and biopharmaceutical manufacturers to make decisions and recommendations with confidence, as well as pursue market opportunities for their products. Source offers comprehensive patient and physician-level prescribing and usage data to provide manufacturers with a unique set of more actionable information than is otherwise available. Source is part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry.

Source: Wolters Kluwer Health

As patients pay more for their prescription drugs whether it’s through higher insurance co-pays or shouldering the full costs many people decide to opt out of taking the drugs altogether. But there are safer ways to cut costs than skimping on or skipping the medicines you need.

More emergency room visits, severe and uncontrolled asthma attacks, and an upswing in heart attacks and strokes are just some of the poor health outcomes associated with skipping a prescription due to its cost.

For a chronic disease like high blood pressure where the symptoms are not obvious, skipping the drug may seem like no big deal, according to Rebecca Snead, executive vice president of the National Alliance of State Pharmacy Associations.

But, “we don’t want someone who can’t afford a medicine to become someone who can’t afford bypass surgery,” warns John Michael O’Brien, a prescriptions cost expert at College of Notre Dame of Maryland.

That’s exactly what happened with to Karen Merrill, who has heart disease. She felt worse when she stopped taking her prescriptions for a while after her heart attack, “and I ended up back in surgery for a bypass,” she said.

When patients decide to stop taking a prescription or otherwise alter their doses without informing their doctors, they may put themselves at risk for overdose or harmful medicine interactions.

“A doctor may think a patient is taking a drug when he really isn’t, and may prescribe another drug when it appears that the first drug isn’t working,” says Michelle Fritsch, a pharmacist and chair of the clinical and administrative sciences department at the College of Notre Dame.

Savings Plan

But maybe your insurance doesn’t quite stretch to cover a brand-name antidepressant, or maybe you are stuck in Medicare’s Part D “doughnut hole,” waiting for your annual cap on prescription coverage to roll over. Maybe you have no insurance and no cash to spend at the pharmacy. How should you handle the costs?

“Every time you fill a prescription, talk to your pharmacist about lowering your drug costs,” O’Brien advises. “Your pharmacist can explain your options and help your doctor choose a medicine that meets your needs.”

However, “I don’t know about you, but I know I would have a hard time standing in line with my pharmacist and saying, ‘I can’t afford this,’” says Merrill, who now works with the American Heart Association as a survivor-advocate.

In many cases, insurance companies directly notify pharmacies about less costly options in a class of cholesterol drugs, for instance, or a new generic version of a drug. “And if a generic is available for a drug you’ve been prescribed, you should take it,” O’Brien says.

People who think generic drugs “are like generic toilet paper” can rest assured that the Food and Drug Administration certifies generic medications as having the same dose, strength, safety and efficacy as their brand-name counterparts, Fritsch says.

Free prescription drugs are available for people who can’t afford their medicines through patient assistance programs or PAPs.

Janet Walton, deputy program director at RxAssist, says it’s not always the uninsured or the poor who are seeking help: “People who are underinsured are calling.”

Merrill sets aside money in a special health savings account to pay for her prescriptions throughout the year, “but come November, December, I’m in my doctor’s office begging for free samples,” she says.

“Samples aren’t a replacement for continuity of care,” says O’Brien, who notes that irregular use of samples can make it difficult for pharmacists to catch drug interactions. Doctor office samples also tend to be expensive brand-name drugs, not generics, “so if you start on a brand-name drug, you’ll soon get a prescription for a brand-name drug.”

Snead and others advise against buying cheaper prescription drugs from Canada, Mexico, and other foreign markets. “The incidence of counterfeit drugs is rising exponentially,” Snead warns. Your online pharmacy may be stamped with a maple leaf flag, “but how do you know that the Web site is really in Canada?” she asked.

Speak Up and Cut Back

“One of the questions that I’ve trained my 77-year old mom to ask is, ‘if I get a new medication, which one of these other medications can I stop taking?’” Snead says.

O’Brien and Snead both recommend a yearly review of all medicines, in consultation with your doctor and pharmacist.

Source: Health Behavior News Service