Promoting Safe & Appropriate Drug Use a health literacy perspective

1. 2nd Annual Julia Berg Memorial Lecture – University of Minnesota Department of Pediatrics Promoting Safe & Appropriate Drug Usea health literacy perspective Michael S. Wolf, PhD MPH Associate Professor, Medicine & Learning Sciences Associate Division Chief, General Internal Medicine Feinberg School of Medicine Northwestern University Chicago, IL, USA

2. Disclosures.

3. A Prescription for Confusion.

5. September 22, 2009

6. September 22, 2009 ¾ teaspoon dose: 5 ml (volume of teaspoon) x .75 x 12 mg per ml Tamiflu suspension = 45 mg on syringe

7. A Glance at Patient Compliance. • 60% of asthmatic adults don’t properly use inhalers • 54% of U.S. adults don’t get annual flu shots • 50% of diabetic patients are non-adherent to Rx regimens • 49% of eligible adults have not received CRC screening • 40% of adults don’t know signs of a heart attack • 40% of hypertensive patients can’t identify their medicine

8. A Glance at Patient Compliance. • 60% of asthmatic adults don’t properly use inhalers • 54% of U.S. adults don’t get annual flu shots • 50% of diabetic patients are non-adherent to Rx regimens • 49% of eligible adults have not received CRC screening • 40% of adults don’t know signs of a heart attack • 40% of hypertensive patients can’t identify their medicine Do Patients Understand their Role?

9. A Problem from the Beginning. • 55% of children under-use preventive asthma medicine • 50% of young adults w/ chronic conditions do not successfully transition from pediatric to internal medicine • 33% of young adults lack knowledge of meningitis risk and symptoms • 20% of teens 15-19 years old report not using contraception during last intercourse episode • 17% of children taking Rx drugs will experience a dosing error (leading to 250,000 adverse events annually)

10. Medication Error. • Most common form of medical error. • > 500,000 preventable adverse drug events (ADEs) occur in ambulatory care annually.1 • Cost: > $1 Billion/year • Majority of studies among adults • Recent surveillance (2001): 250,000 ADEs occur in children and adolescents in outpatient settings annually2 • 1 in 6 children taking an Rx drug will experience a medication dosing error 1Institute of Medicine, Preventing Medication Error, 2006 2Cohen, Budnitz, Weidenbach, et al. J Ped 2008

11. Root Cause – Misunderstanding. • IOM 2006/2008 reports identifies unintentional misuse a leading root cause • In outpatient care, patients and their families assume quality control, NOT physicians • MEPS Data (1996-2003) shows increasing trend – patients of all ages taking more Rx drugs Do patients and families have the necessary skills?

12. Understanding and Promoting Health Literacy Help patients and families: • Understand their health & healthcare • Translate knowledge to recommended actions • Apply problem-solving skills to new situations • Foster ongoing health learning opportunities • Instill health-promoting attitudes

13. Understanding and Promoting Health Literacy Help patients and families: • Understand their health & healthcare • Translate knowledge to recommended actions • Apply problem-solving skills to new situations • Foster ongoing health learning opportunities • Instill health-promoting attitudes

14. Understanding and Promoting Health Literacy Help patients and families: • Understand their health & healthcare • Translate knowledge to recommended actions • Apply problem-solving skills to new situations • Foster ongoing health learning opportunities • Instill health-promoting attitudes

15. Understanding and Promoting Health Literacy Help patients and families: • Understand their health & healthcare • Translate knowledge to recommended actions • Apply problem-solving skills to new situations • Foster ongoing health learning opportunities • Instill health-promoting attitudes

16. Understanding and Promoting Health Literacy Help patients and families: • Understand their health & healthcare • Translate knowledge to recommended actions • Apply problem-solving skills to new situations • Foster ongoing health learning opportunities • Instill health-promoting attitudes

17. Health Literacy Reading and Beyond Simplified Model of Health Learning Wolf, Wilson et al. Pediatrics 2009

18. Health Literacy: What We Know • Use of preventive services • Delayed diagnoses • Understanding of medical condition • Adherence to medical instructions • Self-management skills • Risk of hospitalization • Physical and mental health • Mortality risk

19. The Impact of Limited Health Literacy $106 -230 billion per year - Friedland, 2002, Vernon et al. 2007

20. Understanding Primary Rx Label Instructions: “Take Two Tablets by Mouth Twice Daily” 2:3 1:3 1:5 Wolf et al, Annals of Internal Medicine, 2006

21. individual abilities vary…

22. yet messages are often unclear

25. The Goal for Public Health & Medicine. Find Ways to Match Healthcare to Average User Ability CLOSE THE GAP

26. Contextualize the Problem.

28. Health Literacy Targets. • Individual skills – improve learning & retention • Health materials – examine modality, improve design • Clinician skills – consider communication strategies • Health system design – human factors

29. Health Literacy Targets. • Individual skills – improve learning & retention • Health materials – examine modality, improve design • Clinician skills – consider communication strategies • Health system design – human factors Comprehensive Strategies Needed!

30. An Abundance of Low-Hanging Fruit.

31. Preeclampsia (prē-i-klam(p)sē-ә\): a serious condition developing in late pregnancy that is characterized by a sudden rise in blood pressure, excessive weight gain, generalized edema, proteinuria, severe headache, and visual disturbances and that may result in eclampsia if untreated.

32. Variability in the Message… 53 Different Ways to Say ‘Take 1 Tablet a Day’ Take one tablet orally once every day. Take 1 tablet by mouth every morning. Take one tablet for cholesterol. Take one tablet by mouth once daily. Take 1 tablet one time each day. Take 1 tablet 1 time daily. Take one pill by mouth at bedtime. Take one pill by mouth once each day. Bailey, et al., Annals of Pharmacotherapy, 2009

33. Variability in the Interpretation... Wolf, et al., Medical Care, 2009

36. Goal: Reduce Cognitive Load. • Provide plain language directions • Be concise, explicit • Sequence information w/ consumer perspective • Use meaningful visual aids only!

37. Do not use if - you are pregnant - think you are pregnant - breastfeeding Goal: Reduce Cognitive Load. • Provide plain language directions • Be concise, explicit • Sequence information w/ consumer perspective • Use meaningful visual aids only!

38. Unnecessary Complexity

39. Reprogramming the Rx Label. Michael Wolf 04/29/71 Rx #: 1234567 9/8/2009 Do not drink alcoholic beverages while taking this medicine You have 11 refills 180 pills Glyburide 5mg Take for Diabetes Discard after 9/8/2010 Carry or wear medical identification stating you are taking this medicine Provider: RUTH PARKER, MD Emory Medical Center (414) 123-4567 Take: 2 pills in the morning 2 pills in the evening You should avoid prolonged or excessive exposure to direct and/or artificial sunlight while taking this medicine Pharmacy: NoVA ScriptsCentral 11445 Sunset Blvd. Reston, VA (713) 123-4567 Morning 7-9 AM Noon 11-1 PM Evening 4-6 PM Bedtime 9-11 PM 2 2 NDC # 1234567

40. Standardize Dosage Devices. Pediatric Dosing Instruction Sheets Yin, Dreyer, van Schieck, Arch Pediatr Adol Med 2008

41. Provider Communication Skills. Three common strategies: • ‘Teach Back’ (Current recommended standard) • Teach-to-Goal (Learning Mastery) • Guided Imagery (Implementation Intention)

42. Provider Communication Skills. Three common strategies: • ‘Teach Back’ (Current recommended standard) • Teach-to-Goal (Learning Mastery) • Guided Imagery (Implementation Intention)

43. Provider Communication Skills. Three common strategies: • ‘Teach Back’ (Current recommended standard) • Teach-to-Goal (Learning Mastery) • Guided Imagery (Implementation Intention)

44. Provider Communication Skills. Three common strategies: • ‘Teach Back’ (Current recommended standard) • Teach-to-Goal (Learning Mastery) • Guided Imagery (Implementation Intention) Guided Imagery (Implementation Intention)

45. Action-Oriented Self Care. • ACP Guide: a Low literacy, print self-care tool • Brief, plain language messages • Supportive pictures, graphics • Patient narratives • Chunked information • Non-linear approach

46. Education is not a One-Time Endeavor! • Follow-up necessary to move patients forward. • Front load activities. • ACP Guide – min. 6 follow-up calls or in-person encounters 0 1 2 3 4 5 6 7 8 9 10 11 12 Baseline clinic visit Telephone call follow-up Clinic visit OR telephone call follow-up Carve-In vs. Carve-Out?

47. Standards Needed. • Health materials • Communication training (“universal precautions”) • Coordination of care processes • Measurement/evaluation indicators Set Policy, Health Provider Incentives • Medicare Part D: Medication Therapy Management • KP Plan:Stanford Patient Self-Management

48. Teach Roles & Responsibilities. • Use schools to familiarize youth with health system • Identify roles by age group • Train children and teens on specific health skills • Opportunities for family education • The value of anticipatoryguidance!

49. September 30, 2009 Change can happen…

50. Contact Information:Michael S. Wolf, PhD MPHAssociate Professor, Medicine & Learning SciencesAssociate Division Chief – ResearchDivision of General Internal MedicineNorthwestern University Feinberg School of Medicine750 N. Lake Shore Drive, 10th FloorChicago, IL 60611(312) 503 – 5592mswolf@northwestern.edu