USA Today recently reported on a study where medication blister packs were used to improve patient compliance. Blister packs are those cards of pills backed with foil that are used by many over the counter cold remedies. In this study the pharmacist tossed aside the normal pill bottles, and combined the patient’s daily medications into one set of custom blister packs. For each dose time, there is a pre-filled collection of medications to swallow. According to the researchers, compliance was much greater than normal; patients did a better job of taking their medications.
As an experienced pharmacist dedicated to the issues of patient adherence and medication compliance, I don’t have any problems with what was reported. However, I have a problem with what was not reported.
Blister packs have been around for years. They’ve mainly been used in nursing homes or similar care settings, but only one drug is packaged and dispensed per card. The multi-pill-per-cup idea reported by USA Today has been tried for many years by pharmacists independently trying to help their patients handle this complex task more easily at home. But there are many issues with the method which were not mentioned in the article. Here are some I am familiar with:
- Cost: Even though this article implies that blister packs are a cost-effective means of packaging medications, the material cost they cite is only part of the overall cost:
The blister packs were cheap; each cost just 14 cents a month to produce
Wow! Fourteen cents sounds good, but 14 cents just pays for the actual packaging materials. I’ve used these “bingo cards” in my practice as a pharmacist and it takes the pharmacist a lot more time to divvy up an assortment of pills into each of the blister pack cups than it takes to fill pill bottles. This is a labor intensive process. Pharmacist/technician time is money, too. I can’t see how that additional cost could have been counted within that 14 cent accounting. Also, remember that modern pharmacies continue to improve efficiency through automation, and this custom blister pack approach can not be achieved with the same automated, computerized pill counting systems in place at pharmacies today. Someday maybe, but not today.
- Expert Judgement: One of the real hard issues faced by patients taking multiple medications (often prescribed by different healthcare professionals), arises from the communications disconnect between those prescribing doctors. Often the specific instructions provided by separate doctors for different medications seem to contradict. One may say “take with food” while another is labeled “after meals”. While this may seem to be a trivial conflict to a trained healthcare practitioner (such as a pharmacist deciding how to prepackage those medications into a blister pack), it can stymie a conscientous patient trying her best to adhere to instructions. Again, the pharmacist loading custom blister packs is handling those sometimes complex decisions on behalf of the patient. Again, not included in that $0.14 cost estimate, and neither are the phone consultations a good pharmacist will initiate when truly conflicting instructions are discovered.
- Errors and Liability: Whenever medication prescriptions are filled, there is a possibility of a filling error. Patient safety is addressed through quality control (check, double check) and it is safe to assume that more complex combinations bring more opportunities for filling errors (even if we don’t recognize that automated pill counters and pill inspection machines are already on the job in many pharmacies). With a custom blister pack, a pill may be left out by mistake, or 2 of the same pills may wind up in the same cup. How can anyone double check, or triple check that? And who shoulders the added responsibility for that additional Quality Control?
- Flexibility: Not every prescription is a fixed, long-term solution. What happens if a doctor changes the patient’s meds in mid-month? What happens to the pre-packed blister cards that have already been made? Some pharmacies may pick up the unused blister packs and re-use the medications in a new assortment, but legally this is a gray area because the drugs have not been in pharmacist custody the whole time. Can they be safely re-distributed? Even to the same patient? There is also the obvious additional labor of collectng, breaking open, and re-packaging, which must be balanced against the alternative costs of simply throwing the unused drugs in the disposal. Some patients may be able to pick out pills that have been discontinued, or find a way to make it to the next delivery of properly configured blister packs, but, I wonder, will that aid in adherence or hurt it?
- Safety: Prescribing doctors are not the only health practitioners concerned with drug safety. The intended patients are not the only people who handle these medications. Medications are packaged with disclosure documents describing side effects, hazard labels and even accidental poisoning data in some cases. Poison control technicians and their pharmacist directors have worked very hard to get these materials into the packages and onto the labels. If we “toss aside” the pill bottles and pre-package combinations, where is the documentation? The labeling of custom blister packs can get very complicated in order to comply with state and federal laws, thereby adding an additional layer of confusion to this “simplification” process.
- Compliance: Packaging is not the only barrier or answer to compliance. Many patients will still need a reminder to take their medications, even if the blister pack does make it easier to adhere to the proper dosing regimen. I can imagine a new crop of questions that need to be answered, such as “I missed one dosage of everything. Do I play catch up and take all of them together, as soon as possible? Should I skip some, but be sure and immediately take others, and if so, which ones?”
Think about this: if the patient forgets to take a pill out of a bottle when it’s time to take a dose, wouldn’t it follow that the same patient might also forget to pop open the blister as well? What tells this person when it’s TIME to take a medication out of any container? Do they rely on some internal clock or daily routine to remind them? Do they set an alarm clock or use some other alerting device?
This system of blister packs certainly can help some patients, but I don’t think it is a universal compliance “answer”.
Finally, according to the report:
“Your grandmother isn’t going to take her pills if she doesn’t know why the doctor gave them to her”, says Allen Taylor
I’ve known plenty of conscientious patients who take a variety of pills routinely while having no idea what they are for or why the doctor prescribed them. This is exactly why I believe Medication Therapy Management services (Medicare Part D) is so vitally needed. Under the MTM scenario, an independent pharmacist serves as a patient advocate, and takes an unbiased look at all of the medications a patient is taking, at least once a year or every 6 months. That review provides additional expert judgement, helps in overall safety and quality control, and can facilitate the additional communications that might be needed when multiple medications are prescribed by separate doctors. Every patient should seek the services of a pharmacist/patient advocate who will look at the big picture and advise accordingly.