Delivering adherence packaging to effect medication synchronization would at first seem...to the casual observer...an easily achievable but robust endeavor. It is...but what approach is best from a patient and also, pharmacist perspective?
One pharmacy I recently visited had implemented a multiple-dose strip pouch packaging effort to ensure medication adherence and synchronization for patients. At time of delivery to the patient, the pharmacist...within the possible 30 minute medication therapy management (MTM) session...presented some 60 strips, for daily use, packages(consistent with a 30 day supply) of 11 different multi-dose packaged medications that included daily or non-daily dosage medications to the patient. Is this the best way pharmacists can ensure patient medication adherence?
With the opportunity for medication synchronization (ie, all prescriptions for the month are picked up at one time monthly), pharmacists are offered the opportunity to better explain how all medications being taken (by the patient/customer) work together to effect the better therapy prescribed by the practitioner and increase patient engagement to advance therapy and medication adherence. Unbeknownst to most pharmacy patient/customers is the new "star-rating" performance system implemented by CMS (Center for Medicare and Medicaid Services) for both pharmacies and patient insurance plans. It is an evaluation (performance) that explores and assesses some 50 different quality measures in targeted areas of patient health (chronic illness therapy outcomes, adherence etc.). Pharmacies and health plans are now being monitored on a 1-5 star rating system...the higher the star rating, the larger the performance bonus ($) the health plan receives as part of its yearly audit. For this reason, many health plans have started direct-to-consumer campaigns using their "star-rating" to enlist additional enrollees. Additionally, pharmacies who bill the health plan for medication reimbursement are now being challenged, by the health plan, to improve their pharmacy star-rating. Integral to this star-rating performance for pharmacies is their responsiveness to general patient engagement areas of medication adherence, medication synchronization and the larger pharmacist opportunity-medication therapy management (MTM).
Medication therapy management (MTM) is much more than adherence and synchronization. It includes, by definition, some nine different areas of pharmacist-patient engagement: Medication therapy reviews, pharmacotherapy consults, disease management coaching/support, pharmacogenomics application opportunities, anticoagulation management, other clinical services, medication safety surveillance, health/wellness/public health awareness and immunization.
As a currently registered pharmacist in several states...and past dosage form formulator for various Pharma organizations...what's the best approach to insuring medication synchronization and medication adherence? Medication synchronization can certainly be an assist...yet which adherence packaging approach is best? The best answer my patient/customers and recent pharmacy owners visited offered to me: NO STRIP PACKAGING. Why?
From the patient perspective, who receives perhaps 6-12 or more different prescriptions per month, the medication synchronization concept is seen as a value-based service. Pharmacists are sensitive to reducing multiple visits per month for any individual patient/customer as gas prices and travel inconvenience can impact, for some, the ability to pay for and pickup necessary medications. For pharmacists, the trade-off for regular visits by patient/customers (more than one per month) is reduced conversation about ensuring the healthcare plan being offered is understood by the patient/customer and potential reduced "pharmacist-patient bonding".
However, from a dosage formulation scientist/pharmacist perspective, if using multi-dose (more than one dosage form in the same "pouch") strip packaging, what is the possibility that one dosage form can "cross contaminate" another while being adjacent another while in the multi-dose package? Are any of the dosage forms Nitroglycerin? How about packages that contain antibiotics or penicillins? What about liquid gel dosage forms? What about using different lots of the same medication within the monthly strips needed? How preclude mixing expired meds with non-expired meds?
Dosage form formulators, when developing new dosage forms, evaluate what are known as solid-solid interactions in various storage conditions and in contact with various packaging materials. These studies are completed to effect the necessary expiry date for continued effectiveness (potency) and safety (no damaging degradation by-products). Although an expensive exercise, drug manufacturers (Pharma) conduct these tests in various climate conditions (heat, cold, humidity, intense light, different packaging materials etc.) to ensure awareness of any possible change to the dosage form. What might happen when multiple dosage forms "sit" next to each other in a single pouch...as is now offered as part of an adherence packaging approach for ambulatory patient/customers by some automated packaging/dispensing organizations? Should multi-dose strip packagers do the same studies?
Strip packaging works well when a care-giver (such as a nurses or CNA) provides the medication in prescribed dosage regimens to a patient or resident in skilled nursing or long term care facilities...perhaps 3-4 times daily. Releasing the medication adherence function over to an ambulatory elderly individual patient/customer...through strip-pack use training seems a "stretch" from a compliance standpoint...not to mention the difficulty many older patients have in opening anything that is shrink-wrapped or package sealed (an analogy--are mustard and ketchup single packets easy to open?). How many patients have vision problems that might preclude correct use? Many pharmacists are able to offset this problem for their patients, when using vials, by placing on the vial cap an initial to denote for which condition the med is being used.
What might be your choice for packaging to improve medication adherence and medication synchronization while allowing a less confusing use dialog with your patient/customers? Pharmacists can teach themselves how single dose vials, with just one medication within, is more understandable by patient/customers as to how to take the medication and the role it plays in the therapy healthcare plan being prescribed by the practitioner. When a pharmacist is performing MTM or merely counseling a patient/customer, once a month, the time alone to educate the patient/customers is greatly different between explaining single vials in contrast to strip packaging. What's best? As an example, contrast 11 different medications in 11 vials with up to 350 individual strip packages offered to the patient/customers to complete the monthly regimen. Can patient/customers know where to "tear"?
In addition, mid-cycle changes to the patient's drug therapy (i.e. discontinued medications, dosing changes, etc.) would effect a complete "recall" of all the medication strips in such a model; increasing confusion and the potential for dispensing errors.
Medication synchronization is best completed using single dose vials...already known to patient/customers. More time during counseling can be spent on advancing medication adherence rather than describing the new adherence packaging used...and doing strip package use training.