HELP THE MEDICINE GO DOWN

DAVID VACZEK

Supermarket pharmacists, in common with their counterparts in other community pharmacy settings, are involved every day in promoting the correct use of medications.

New strategies for promoting compliance with drug therapy, such as letter reminder programs, besides helping patients avoid drug misadventures, are adding to food-store pharmacy sales and traffic, supermarket pharmacy directors said.

No single approach will solve the major problem of patient noncompliance, it was said. But community pharmacies, as accessible, frequently visited sites, are situated to provide the type of ongoing care many experts say is necessary if drug misuse by patients is to be controlled better.

Visiting their home-bound patients weekly, nurses have learned to rely on pharmacists at Jitney Jungle Stores, Jackson, Miss., for answers about patients' medications, thanks in part to the chain's letter refill reminder program, which helps alert care givers about where patients had prescriptions filled and their refill status.

At Carr Gottstein Foods, Anchorage, Alaska, patient underuse and overuse of drugs is often discovered and corrected by the pharmacist while adjudicating claims over the computer, when third-party managers send prompts if a patient's drug use falls outside normal limits.

"Staying up to speed on all the new drugs is difficult. In adjudicating third-party claims a pharmacist may be prompted to call the doctor and double check the prescription or dosage if they fall outside Food and Drug Administration-approved guidelines. Pharmacists are alerted if the prescription has already been filled somewhere else," says Martin Krull, director of pharmacy.

At Buehler Foods' Buy-Low Stores, Jasper, Ind., pharmacy customers get a helpful nudge when walking the aisles from shopping-cart signs asking, "Did you remember to pick up your prescription?"

Ensuring compliance is integrated into the process of filling and refilling prescriptions at many community pharmacies.

A 1996 study of 28 pharmacies by the University of Kansas on the range of pharmacists' services found that almost one-fourth of pharmacists' interventions in drug therapy involved compliance, including overuse or under use of drugs. An additional one-third of the pharmacists' actions were directed at answering patient questions and counseling.

The pharmacists' monitoring, studied over a month's time, saved, on an annualized basis, $12 million in avoided health costs, the study found.

But there is still a lot of room for improvement.

When patients misuse their drugs or fail to take them, the health system incurs huge costs from expensive, avoidable, additional care, mostly hospitalizations. Costs from preventable drug misuse, including noncompliance by the patient, in the ambulatory setting alone in the United States amounted to $76.6 billion, according to a landmark 1995 study by the Center for Pharmaceutical Economics at the University of Arizona.

Barriers to patient adherence remain high. The inconvenience of taking drugs, their cost, and patients' beliefs and attitudes are some reasons inhibiting compliance. Illiteracy -- patients' inability to understand labels and written materials -- is a major obstacle to correct drug use.

"Drugs are a commodity that nobody wants; they cost you an arm and a leg, and sometimes they make you feel worse than you felt when you were not taking them," said Paul Doering, professor of pharmacy at the University of Florida in Gainesville.

An industry focus on development of user-friendly drug labeling, and on high-quality printed material dispensed with new prescriptions will help achieve higher compliance rates, some believe. However, many experts say the issue has to be addressed more intensively, through oral counseling with the patient. Face-to-face counselling, the active involvement of patients in their care through an equal partnership between patient and clinician, and regular follow-up with the goal of motivating patients, are approaches favored by many experts.

"There has to be an ongoing dialogue with the clinician; this is where the pharmacist can step in and be that intermediary," said Arthur Kibbe, department chairman of pharmaceutical sciences at the University of Wilkes-Barre, Pa.

Adoption of pharmaceutical care practice models is a step in this direction; pharmacists in these new formats more closely assess the needs and capabilities of patients with serious diseases such as diabetes, hypertension and heart conditions, and help them track their progress in taking their medications and controlling the disease.

Other less labor-intensive approaches to noncompliance also work, and, besides helping patients stay healthy, provide additional store revenues, say supermarket pharmacy directors.

Letter programs are springing up, putting to use pharmacies' data on scripts filled and days-of-supply. Hiking refill rates, they are also effective marketing tools for the pharmacy by reaching out to patients and their health care givers.

Spurring this trend are letter programs managed by third parties, including drug wholesalers and pharmacy computer vendors, which pick up the stores' data, manage the letter reminder program and enlist drug manufacturers to help pay for the service.

Jitney Jungle Stores is using a program by Condor Corp., Pelham, Ala., a pharmacy computer company, by which Condor pulls back the data on prescriptions filled and days of supply, and mails letters to patients prospectively, to arrive four or five days before the refill date.

Refill rates at the chain increased by 8% to 10% for the approximately 20% of chain drug customers who receive the letters, said Clarence Lea, vice president of pharmacy.

"When we have competition in a market, or if we are opening a new store, I will increase the amount of reminders we send. We might, for example, add birth control pills to the mix. I can tailor it by patient, on a weekly basis, and by store," said Lea.

"People respond incredibly to it, and it creates a dynamic between the pharmacy staff and the patient. This says 'we want to be involved with you after you leave this store.' "

The letters promote a dialogue with other care givers by providing written records patients can show their doctors or nurses. And, "this is very non-labor intensive; the pharmacist doesn't have to do a thing," Lea added.

Buehler Foods is able to participate in a new refill reminder letter program being launched by its wholesalers after having upgraded its pharmacy software. The chain's 11 pharmacies in Buy-Low supermarkets will be involved in a beta test with drug wholesaler Diversified Healthcare Inc., Evansville, Ind., with reminders managed by pharmacy computer company ComCoTech, said Russ Imbler, Buehler pharmacy coordinator.

Imbler anticipates refill rate increases of 10% to 20% from the program, which will send letters prospectively.

"This should work to the advantage of patients [by keeping them compliant], to us through more refill business and theoretically it's saving the insurance companies money [by helping avoid costs from drug misadventures]," Imbler said.

Drug manufacturers who participate and provide rebates based on refill rate increases, which will be shared with the retailers, also will gain from the program, noted Robert Leich, DHI president.

"Ultimately, most retail organizations, whether supermarkets, independents or drug chains, will be involved in this type of activity, if they are not already," Leich predicted.

McKesson Drugs, San Francisco, through its ValuRite\CareMax information access network, has, since last year, offered a similar compliance program to 3,100 community pharmacy network participants. The Wholesale Alliance, Minneapolis, a national organization of 20 regional drug wholesalers, recently launched a letter compliance program.

Other chains are considering in-house programs. Quality Food Centers, Bellevue, Wash., may launch its own program this fall after installing its first central pharmacy system, linking the pharmacy databases in its 12 supermarket pharmacies, said Vic Grutchfield, pharmacy director.

"Rather than putting the burden of the program on the individual store, we can, once a week, download prescription and days-of-supply information for given therapeutic classes, and then send out the reminder letters, either prospectively or retrospectively," said Grutchfield.

Letter programs have become a feasible option for many supermarket pharmacies. But for many patients a post card will not be enough to ensure drugs are used correctly and to completion. Community pharmacies' increasing focus on personal care may provide the ultimate solution to this problem.

"You have to be friends with your patient. That is the most effective approach," said Imbler, a second-generation pharmacist.

"It's a matter of building rapport; getting the pharmacist out from behind the counter. One of the best things you can do is talk with the patient," said Imbler.