Published in the May 2008 issue of Today’s Hospitalist
AS A HOSPITALIST, it’s disheartening to spend 20 minutes at discharge reviewing prescriptions with a patient, only to learn from a phone call 18 hours later that the patient is completely confused about her medication. Add a gap in health literacy, a language barrier and high-risk medications such as anticoagulants, and the situation becomes downright scary.
A simple tool developed by researchers at the University of California, San Francisco (UCSF) may help hospitalists address the potentially dangerous communication breakdown between the inpatient and outpatient settings. Called a visual medication schedule, the computer-generated calendar features color images of the medications patients are supposed to take each day, with instructions in both English and the patient’s native language.
The schedule is an offshoot of the old-fashioned approach some internists have used with low-literacy or confused patients: taping pills to a sheet of paper and writing visual-cue regimen instructions. In practice, however, the tool functions at a much higher level.
When researchers at UCSF tested the tool in a group of patients with poor anticoagulation control, the schedule effectively cleared up many misunderstandings about medication instructions.
Even more impressively, patients who used the tool and were asked to briefly “teach back” what they’d been shown by physicians were able to achieve anticoagulation control in 28 days. Patients who received only verbal medication counseling and written instructions, on the other hand, needed 42 days to achieve that level of control.
The study done on the intervention was published in the October 2007 issue of the Joint Commission Journal on Quality and Patient Safety. According to Edward Machtinger, MD, the study’s co-lead investigator, one goal of the visual medication tool is to help bridge the communication gap that sometimes occurs at discharge around medications. If patients might confuse the medications they’re already taking with those they’re prescribed at discharge, a visual reminder of which medications they should take could help avoid a potential overdose or dangerous combinations.
“There’s no reason hospitalists couldn’t discharge patients with a visual sheet that includes pictures of the medications, and doses and schedule,” says Dr. Machtinger, who is also associate clinical professor of medicine at UCSF. “It’s inexpensive, and it might be very helpful in facilitating communication and bridging care continuity” until patients are seen by their primary care providers.
He adds that the visual medication tool “which patients or family members could keep in a handy spot at home “might even save time at discharge and reduce caregivers’ burdens. “It could be very helpful, especially with vulnerable patients or those taking high-risk medications, to have the tool stuck on the refrigerator,” Dr. Machtinger suggests.
Dr. Machtinger developed the visual with co-lead Dean Schillinger, MD, who is director of UCSF’s center for vulnerable populations. They noticed in other studies that about half of patients on anticoagulants were not taking their medications on the prescribed schedule and were not aware of that discrepancy.
That’s when the researchers realized that Chinese and Spanish-speaking patients were at even greater risk for being unable to verbalize their regimen in a consistent way. That was true even when directions were given in the patients’ native language, and when a bilingual research assistant was brought into the picture.
“But we found,” Dr. Schillinger explains, “that those patients were very good at pointing to the pictures when telling us what they were taking.”
He suspects a similar approach could be used in pre-discharge medication counseling by having patients reiterate physician instructions and then refer to the tool to confirm that they’ve understood that information.
Dr. Machtinger adds that hospitalists who have nurse case managers or other personnel assisting at discharge might enlist them in the effort.
Going beyond guidelines
Dr. Schillinger notes that while considerable research has been done on the impact of medication non-adherence, relatively little has focused on the effects of poor or inadequate provider-patient communication about medications.
As a clinician in a public hospital, he says, he’s been struck by how much time and effort is devoted to developing prescribing guidelines. Yet, “relatively little work has gone into figuring out how we can support patients to take these medications correctly.”
Drs. Schillinger and Machtinger suggest that by virtue of its simplicity, the visual medication schedule could be customized to include any number of medications.
“I think that the intervention is flexible enough that if someone developed a national database of visual medication images, this tool could be used with every medicine,” Dr. Schillinger says. “But in the absence of FDA guidelines or legislation mandating standardized labeling, implementing the tool would require clinical champions” to promote system-wide use.
Other barriers, he concedes, could be patients who go to multiple pharmacies or community physicians who wouldn’t support using the tool when inpatients return to those practices post-hospitalization. Finally, it might be hard to generate the tool for patients taking more than five or six medications.
High-risk, high-value drugs
Dr. Schillinger notes that the schedule has been implemented in the anticoagulation clinic at New York’s Bellevue Hospital Center. It has also garnered substantial interest among California safety net hospitals as a way to address the health and language literacy obstacles providers face in that state.
Besides the obvious benefits in anticoagulation care, Dr. Machtinger says the tool is ideal for a host of other medications that are either high-risk, high-value or both.
“This would be particularly good for those kinds of drugs where the medications are a miracle, like those that have changed HIV from a chronic disease to a chronic treatable illness,” he says. “But it also would be valuable with any disease that requires almost perfect medication understanding and adherence, like organ transplant immunomodulating medications or cancer chemotherapy.”
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.