Getting Patients to Goal

The Right Medications in the Right Combinations at the Right Dose

Shelley Wood; Robert Harrington, MD; Renu Virmani, MD; Stephen Nicholls, MBBS, PhD


November 11, 2013

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Ms Shelley Wood: Hi. I'm Shelley Wood, the managing editor for heartwire , and my guests here today are Dr Bob Harrington, Dr Renu Virmani, and Dr Stephen Nicholls.

Our topic is getting patients to goal. I described that as a euphemism before we started taping because really what we're talking about is getting patients to take their medication at a dose that will actually help them. So we kind of batted around a few theories as to how we could do this, but why don't we start with you, Bob. What's your best idea for how to get patients taking the drugs they need at the right dose?

Robert Harrington, MD: I wish I had the best idea, because this is a really difficult topic whether we're talking about the patient with coronary disease, at risk for coronary disease, with heart failure, with hypertension—we as a medical community and patients as a community don't do a good job together getting to where we need to be. We don't take the right medicines. We don't take them in the right combinations, and we don't take the right doses.

I think it needs to really come down to the physician members of the team—and I'll stress the word team—really emphasizing the importance. Then you need a team built around it. You need nurse practitioners, PAs, PharmDs, medical assistants—but it really becomes a team effort. The best evidence is that when you utilize a team approach we can get better. We never quite get great, but we can get better.

Wood: Well, is this an issue of ticking off a box? Because we talked about pay for performance a little bit, where you know that a patient needs to be a on a certain drug. You give the drug to them and you tick the box and it's done, but actually this is not an effective dose. Several groups have looked at this recently.

Harrington: Right.

Wood: Dr Virmani, how do we take it from a tick box—yes/no is the patient on the drug—to knowing that they're taking the right amount of it at the right time?

Renu Virmani, MD: I think one of the things that has been done socially, and people have done it by having social workers visit the patient's home every week or two weeks and making sure the number of pills that is given is counted and seeing that they were taking it. Maybe we need blood levels to be able to make sure that they can, but I think that's a little going too far. I think the other thing that can be done is physicians don't have the time or the patience to talk to their patients because it takes a long time to explain how important it is. Maybe we need nurse practitioners who will explain to the patient [and] spend time [with them on] how important it is that they take their medication all the time.

Wood: So back to the team idea again. You're rolling social workers into this now too. Dr Nicholls?

Stephen Nicholls, MBBS, PhD: Well, it's about system-based approaches, isn't it? Ultimately the system has to be responsible for getting our patients to goal because it's ultimately the system that's going to have to deal with the morbidity and the mortality that we're going to suffer if we don't get those patients to goal. We talk a lot about at meetings such as the [European Society of Cardiology Conference] ESC about getting LDL cholesterol to 40 mg/dL and getting blood pressures to 120 mm Hg. I have enough trouble getting my patients' LDL to 100 mg/dL—that's a real challenge—and their blood pressure to 140 mm Hg. So it's a big challenge. We're going to need to think that it's not a one size fits all.

Salim Yusuf presented some really intriguing data here at the ESC about the PURE[1] data set of 155 000 patients and looked at what the drivers of disease were in both urban and rural systems in different countries. It's not going to be a one-size-fits-all kind of approach. You know, we're going to have to have systems approaches that work in advantaged and disadvantaged kind of populations. I think the other part of all of this that is going to be the bigger challenge for us moving forward is that it's almost easier to sort out how to deal with attaining goal in advantaged societies. Trying to deal with it in disadvantaged [ones] is going to be a much bigger problem with very different challenges.

Harrington: Yeah, I mean I think that one of the issues, as Steve is bringing up, is the notion that the system is going to be responsible for a population—

Wood: Just by system—because we're all using that word—but you're talking about the government-mandated form of healthcare delivery?

Harrington: No, I'm talking about, say in the United States, the system that takes accountability for a population. So for example, in my area Stanford will have an accountable-care organization for which we have agreed with some insuring agency to provide a certain type of care for that population of patients. It is going to be us in the system who are held accountable. It's not going to be good enough to check the box anymore because the box that's going to need to be checked is patient outcome.

Virmani: Which is going to take a long time.

Wood: It sounds expensive.

Nicholls: Well, it may not be, though. You look at the technological advances that we're going to be able to take advantage of. Electronic medical records, social media—how we start to really innovatively integrate that into the way that we look after our patients. I don't think it's going to be that expensive. We need to start thinking in an innovative fashion about how we can do that in a cost-effective way. We're going to do clinical trials that way as well, which is kind of another cool kind of benefit of all that.

Harrington: I mean the social media space is just being scratched.

Wood: Everybody says social media is going to be the answer to everything.

Harrington: Tremendous peer pressure. The patient-advocacy groups have seen that the patients particularly who have unusual diseases, rare diseases, catastrophic diseases—

Wood: That I can understand, there's a clublike feel, but are you going to tweet that you took your cholesterol drug today? I don't know. I can't quite.

Harrington: What if you didn't take it and your mother tweeted you and said, hey, you didn't take your medicine today? I think that those types of techniques of peer pressure, support groups are all going to be looked at. Now the key thing is they're going to have to be studied and understand is this worth the investment.

Wood: Dr Virmani?

Virmani: I think it needs to come from within the family. You know, it could be the family unit that takes responsibility—not just one patient but the whole family. It could be kids motivating the parents and saying you haven't taken your medication. Just like we did with smoking. How did we get rid of smoking, at least in the United States? I think we educated the children and we started telling the children: "Tell your parents they must not smoke." I think those kinds of things will help. Also, you could take the advantage of media by saying you have to tick off on your computer that you took your medication. Something like that you could do.

Harrington: I mean it's interesting. We've all seen Dr Fuster present his work from Sesame Street. When you do utilize educational modalities that are appropriate for kids the parents actually respond.

Wood: I'm wondering, too, though, we've talked a lot in the past about number of drugs. So you might have your daily little pill container and you pop it open and there are eight or six things in there. The polypill is a separate discussion point, but given that it's hard enough to take five pills unless all those pills are perfectly titrated I just think there are so many layers to this problem. I'm not a physician, so I don't need to worry about this, but you guys do.

Nicholls: Well, I think we do need to find simpler ways to manage risk in our patients. I know we talk a lot about personalized medicine, and a lot of that may be a little way off, but maybe that's a greater way to be able to enhance compliance, in that, you know, I say to a given patient: "You know what, this is what drives your disease. So this is the specific therapy that's going to be ideal for treating your risk as opposed to the next patient's." I think, again, there are lots of potential advantages with some of these things moving forward. We have to just see how we can use them.

Harrington: Multidrug therapy is a big issue, right? The average Medicare coronary artery disease patient in the United States takes something like six to seven medicines a day on average. So that means there are some who are up at eight, nine, or 10. There are some who are less than, but they take a lot. If you look at the population-level data if you adhere to one, two, three, four, five, six, seven—you keep getting improvement. So if we can push improvement people are benefitting. The question is, is that the better strategy or is the better strategy to embark upon the polypill? Is it to say, you know, of these four things we really have tested that these two are the critical ones? We've not had those kind of studies.

Wood: Right. So here's a question. You guys must take daily meds or you have in the past I'm sure for something—you don't have to tell me what they are— but what is your strategy that you can share with your patient, perhaps? Share with me. I've got to take iron every day. I always forget. What can you do to every day take what you need to take at the time you're supposed to take it? Any little tips?

Dr. Harrington: Well, I'm a type A compulsive person, so maybe I don't fit, but I take a lipid-lowering agent. It's in my shower bag, and I see it sitting there all the time. I just have gotten into the habit of before I go to bed I take it.

Virmani: I take a lot of pills. I even take antihypertensive. I take a lipid-lowering pill, but I take it—after I brush my teeth, I take my pills. It's just a routine. You have to have a routine.

Routine is the key. You are always reminded. Sometimes when I don't do it my husband tells me, "I didn't see you taking your pill!"

Wood: That goes back to your point of family, doesn't it? It is important.

Harrington: Steve, you're too young to take pills.

Nicholls: I was going to say, I'm younger, I don't take pills.

Wood: You're so healthy.

Nicholls: It really is about routine . . . using your support team to help you do that. You know, I think it takes a village, and that's what it's going to take to kind of reduce risk both in individuals and in societies.

Harrington: Do you use a Fitbit? I mean when I got a Fitbit to count my steps—I look at it all the time. You know, I got to get my 10 000 steps. There are those things that we can do for people.

Wood: You can say—going back to social media, but your iPhone does a certain alarm at a certain time. I've got so many alarms on that thing I don't know what means what anymore.

Anyhow, thanks so much for talking about this with me today. I think it's a big topic, but we've gotten through a little bit of it so thank you and thanks very much.


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