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Poor Quantitative Skills of Newly Insured May Affect Ability to Manage Medications

Cheryl A. Thompson

As the Patient Care and Affordable Care Act brings insurance and the prospect of more health care to the currently uninsured, health care providers should expect these new patients to be “less numerate” than current clientele, a numeracy researcher has advised.

According to Ellen Peters of The Ohio State University in Columbus, 62% of currently uninsured adults likely could not correctly answer the question in the following scenario:

The label on a prescription container of doxycycline states, “Take one tablet on an empty stomach one hour before a meal or two to three hours after a meal unless otherwise directed by your doctor.” This patient forgot to take this medicine before lunch at 12 noon. When is the earliest time in the afternoon that the patient can take the medicine?

Among currently insured adults, she said, the percentage would be 50%.

Numbers pose a challenge. People need at least an intermediate level of quantitative literacy to correctly answer the question in the scenario, Peters explained at a July 18 workshop convened by the Institute of Medicine’s Roundtable on Health Literacy.

Those with a basic or below-basic quantitative literacy level would not be expected to answer the question correctly, Peters said in explaining her figures, which were based  on the 2003 National Assessment of Adult Literacy and information from the U.S. Census Bureau.

Michael S. Wolf, director of the Health Literacy and Learning Program at Northwestern University in Chicago, told workshop attendees that health care providers must do a better job of communicating to patients how to apply medication regimens to daily life.

His group’s research with adult patients suggests that those with low health literacy have a greater risk of self-administering their multidrug regimens more times a day than is necessary.

Literacy level aside, older adults do not consolidate medication regimens in the most efficient manner, Wolf’s group reported in 2011 in Archives of Internal Medicine. Four in five of the study’s participants, when tasked with organizing seven hypothetical regimens into a routine, would not take “1 tablet by mouth twice daily” at the same times as “2 tablets by mouth every 12 hours,” for example.

“We view this as a multifaceted problem,” Wolf said of patients’ confusion with medication instructions, “and it requires a multifaceted solution.”

Make it simpler. Part of the solution lies in improvement and standardization of the tangible information given to patients, Wolf said.

California has already acted on that. Since 2011, the state has required pharmacies to use a “standardized, patient-centered” label on prescription medications dispensed to patients.

Last year, the United States Pharmacopeial Convention acted as well. The standards-setting organization issued United States Pharmacopeia (USP) chapter 17, “Prescription Container Labeling” [see December 15, 2012, AJHP News]. It was developed by the Health Literacy and Prescription Container Labeling Advisory Panel. ASHP’s Gerald K. McEvoy, assistant vice president for drug information, served as cochair of the panel.

Wolf said adoption of the universal medication schedule he helped develop would improve and standardize some of the medication instructions given to patients.

The schedule, first presented to the Roundtable on Health Literacy in 2007, slots doses into four periods of the day: morning, noon, evening, and bedtime. A review of 346,000 prescriptions for oral medications had found that 77% had dose frequencies of one, two, three, or four times daily, albeit worded in a variety of ways. Exclude the oral medications taken as directed by the prescriber or as needed, and those four dose frequencies covered 92% of the prescriptions.

Wolf has reported that standardized instructions, including the explicit use of the universal medication schedule’s four dose-taking periods, improve interpretation, especially among patients with low literacy.

In April, the universal medication schedule received the support of the National Council for Prescription Drug Programs, the group that creates the standards for electronic health care transactions involving medications. Prescribers and dispensers, the council said, should begin incorporating the universal medication schedule into their practices.

While acknowledging that no one yet knows how the schedule will affect clinical outcomes, the council said that having such information is not necessary before adopting something that provides clearer instructions for multidrug regimens.

Multifaceted solution needed. Wolf said patients need assistance in addition to a better label on prescription containers.

Clinical pharmacist Daniel C. Johnson can attest to that. He specializes in cardiology at Vanderbilt University Hospital in Nashville and was 1 of the 12 pharmacists participating in the federally funded Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) randomized controlled study.

Pharmacists outside of a closed health system can have difficulties providing the assistance needed by patients with low health literacy, Johnson said in an interview.

A “pill card” showing all of a patient’s medications and dosage regimens, for example, can be difficult for someone to produce in an effective manner without knowing exactly how each pharmacy fulfills prescribers’ instructions, he said.

“Definitely, getting caregivers involved in the process to help the patient can be very useful,” Johnson said. “Some of the alternative delivery systems—[such as] bubble packing of medications—can be effective; also simple systems like stickers on the pill bottles to signify the number of pills the patient might need to take.”

A follow-up telephone call—by a licensed health care professional or someone following a script—can identify medication issues that patients have had since hospital discharge, he said.

In PILL-CVD, the study site’s coordinator made the follow-up call, Johnson said, adding that “some incredible discrepancies” were discovered.

PILL-CVD, which was also conducted at Brigham and Women’s Hospital in Boston, had a four-component intervention: pharmacist-provided medication reconciliation, initial counseling, and discharge counseling and a follow-up telephone call by the site’s study coordinator one to four days after discharge. During discharge counseling, patients received a personalized, illustrated medication schedule showing why, how, and when—morning or breakfast; afternoon or lunch; evening or dinner; and night or bedtime—they should take each of their medications. This was done for all of a patient’s medications.

Johnson said the study inexplicably did not enroll as many patients with low health literacy as had been planned.

The investigators reported in 2012 in Annals of Internal Medicine that 10% of the study’s enrollees had low health literacy, whereas the national prevalence had been estimated at 26%.

This discrepancy, the investigators explained, could have been a factor in finding that their “health literacy-sensitive pharmacist intervention” did not reduce the occurrence of clinically important medication errors after hospital discharge.

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