Health for life

A new study has found that many people who stopped taking cholesterol-lowering statin drugs were also taking an average of three other drugs that interfered with the normal metabolism of the statins.

The other drugs can contribute to a common side effect of taking statins - muscle pain – and often led people to discontinue use of a medication that could otherwise help save their life, researchers learned.

The interactions of many drugs with statins have been known of for some time, researchers said, but are not being adequately managed by physicians and pharmacists, who could often choose different medications or adjust dosages to retain the value of statin drugs without causing this side effect.

The research, done as part of a survey of more than 10,000 current and former statin users, found that use of medications which interfere with statin metabolism almost doubles the chance that a person will discontinue statin use due to muscle pain.

The issue is of growing importance because statin drugs are some of the most widely used medications in the world, proven to lower LDL, or “bad” cholesterol, and decrease the risk of heart attacks, heart disease, strokes and death. About 20 million people in the U.S. now take statins, and new guidelines have just been issued to further expand the types of health conditions for which statins may be of benefit. Based on those guidelines, the number of statin users could increase to more than 30 million.

The findings were published in the Journal of Clinical Lipidology by scientists from Oregon State University and four other universities or research institutes.

“We’ve known for some time of many medications that can interact with statins, but only now is it becoming clear that this is a significant contributor to the side effects, and often the reason some patients stop taking statins,” said Matt Ito, a professor in the OSU College of Pharmacy and president of the National Lipid Association, which funded this study.

“This issue is something physicians, pharmacists and patients all need to be more aware of,” Ito said. “There’s a lot we can do besides discontinue use of these valuable medications. You can change dosages, use drugs that don’t cause interactions, use different types of statins. Patients need to be proactive in understanding this issue and working with their health care providers to address it.”

Persons who have problems taking statins should discuss options with their physicians or pharmacists, Ito said, and not assume the drug has be to discontinued. A Medscape web site at http://erence.medscape.com/drug-interactionchecker also can help individuals learn more about possible interactions between statins and the full range of medications they may be taking.

Statins are usually well-tolerated, but in the recent survey, a muscle-related side effect was reported by 29 percent of participants. In former statin users, 62 percent of the people said that side effects, mostly muscle pain, were the reason they stopped taking the drugs.

There are many drugs that can interfere with statin metabolism, increase systemic exposure to the statin and raise the risk of this muscle pain, the researchers said in their report. This can include some common antibiotics, cardiovascular drugs, and others taken for treatment of cancer, mental health, HIV treatment and other conditions.

These interactions are not always adequately considered by physicians and pharmacists, however. One recent report found that as many as 20 percent of significant statin-drug interactions were missed in 64 pharmacies.

Besides drug interactions, statin side effects are also more common in women and associated with increasing age, history of cardiovascular disease, and some other conditions. Statin discontinuation has been associated with increased cardiovascular morbidity and death.

Talk about a compelling story that went ignored.
In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesnt mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portals stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, errals and prescription errals as a standard for the medical home.  Finally, the Feds promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

Image from Wikipedia

Months ago, the caffeine-addled Disease Management Care Blog reviewed with the spouse how to pre-set the kitchen coffee brewer for a pot of fresh coffee for the next morning. After listening politely to its earnest instructions, the DMCB spouse rarely set up the brewer.

Which is why the DMCB wasnt surprised by an Iowa Chronic Care Consortium (ICCC) study of how its newly minted medical home coach trainees were being deployed in the real world. The ICCC is a not-for profit organization that was founded in 2002 and offers a training program that prepares health professionals to be members of a medical home team.
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The Consortium surveyed 318 graduates from their program. Of that number, there were 164 responses, yielding a 54% response rate. 83% of the respondents were nurses, while the remainder were medical or office assistants, diabetes educators, dietitians, social workers, physicians, pharmacists or administrators.
 
The good news is that care-management caffeine was available. The majority of respondents reported that they were using their skills to coach patients for self management, care coordination, planning visits and supporting registry use.  The majority also found their work professionally rewarding.

The bad news is that these professionals were not being supported for maximum effect:

55% were still "building support for the position."

48% reported that "office work" was given a "higher priority," often due to physician and administrator resistance.

73% reported that their coaching duties were part time and was in addition to their more traditional roles.

Only 8% were involved in office "change management."

Only 11% enjoyed a pay differential that rewarded their coaching skills.

The Consortiums paper concludes - paralleling the DMCBs coffee-making travails - that a good idea accompanied by well-meaning training is not enough to overcome established clinic routines, business roles and local culture.  The authors recommend that provider payments "change," coaching functions be "operationalized," training programs be "advanced," outcomes be "demonstrated" and that roles be "clarified."

While the DMCB ponders coffee change, operations, advances, demonstrations and clarifications, the DMCB has a far more more fundamental concern for the medical home:

With friends like this, the fledgling medical home movement doesnt need any enemies.

If the clinics that took the time and the money to train these individuals are unable to leverage their skills, disappointing outcomes could end up snatching usual care from the jaws of primary care clinic transformation.

The DMCB has three recommendations:

History Repeats: Years ago, established "disease management" companies had to go on record and oppose start-ups that were offering "faux" telephonic patient counseling programs. The medical home and population health management community, including the PCPCC, likewise cant afford to have clinics going to market with diluted medical home programs that deliver empty process instead of hard outcomes.  All health care is local, and much of the buy-in for the medical home will ultimately be won or lost at that level.  Speak up!
 
Buyer Beware: Payers and insurers need to be wise to the possibility that having a trained health coach on staff with credentials is not the same as having a health coach on line with the patients. On site credentialing may be in necessary that includes review of policies, job descriptions, pay scales and staff interviews.

Build or buy: Primary care clinics need to know that when they buy patient counseling services from a population health management vendor, you get full time on a plug and play basis. That may be a better option for a clinic that is not prepared to both train and fully use an on-site health coach.