The Refill Police

January 15, 2009

How many times have you had to ask a patient "Are you taking your medications?" And then get the response, "Yes, but I ran out a couple of days ago."

On any standard day in clinic, at least one of my patients comes in with a heinous blood pressure prompting the usual litany of questions: do you have any chest pain/vision symptoms/headache/shortness of breath right now?

Then we get to the root of the issue: are you taking your medications? Often, as the case in clinic turned out to be this morning, the answer is “yes, but I ran out (insert number of days here) ago.” This often poses a treatment dilemma in clinic—does this patient actually need a different/new medication or just restart the old one? I have several patients whom have yet to record a blood pressure ON MEDICATION during their visits to clinic because every time they show up they have run out of medication for several days. I have tried instilling this sense of early panic when there are about 5 pills left in the prescription bottle, but after having been on prescription medication myself and playing refill roulette for various reasons, I do understand some of the issue. I hate to admit it, but my most recent refill came when I had one pill remaining. What would have happened if the pharmacy needed to order this particular medication for some reason? Hmm, I guess I would have been off my medications… It seems like a friendly not-so-annoying refill reminder would do the trick.

My question is certainly not a new issue: in the journal Contemp Pharm Pract. 1980, a mailing system was discussed in regard to reminding patients to refill their medications. This post-card reminder service was deemed “effective” in the study, but jumping ahead to the nearly paperless age of the 2000’s: what do we have available now that doesn’t require downing a few trees?

There are many versions of reminders available for actually taking medications, from the newest software on smart phones, to tried and true watch and clock alarms. The pillbox and spouse/adult/child/other family member also serve this sweet purpose, with the off chance of being viewed as a nag somewhere along the lines. These are all great options that are quite necessary for even the most astute of us, much less our elderly family members who sometimes need to keep track of over 10 medications in one day. But how about the actual refills? Is there anything specifically for that function? It turns out there are a number of options.

Several pharmacies including Walgreen, CVS and Rite Aid offer their own refill reminder service. The service is free and often is part of a more comprehensive “medication management” service offered by the pharmacy. E-mail reminders are the preferred method offered on the websites for many national pharmacies, but of course will be limited to those patients with ready Internet access.

In our wonderfully capitalist society there are many private companies offering this service. I cannot even tell you how many names come up when I Googled “refill reminder service,” many of which are private companies. These agencies will often arrange for any version of reminder including telephone or e-mail, but at a cost of course. One company described their reminder service as one that calls the home telephone up to 50 times a day until someone answers to verify the call has been accepted and the reminder given. This sounds a bit nagging to me, I must say, but I am sure it works. Sheesh, anything to get that phone to stop ringing…

Big Brother has also gotten into the act after realizing the importance of medication adherence on health and health outcomes, as well as the millions of dollars being affected by non-adherence to medication regimens. The AHRQ division of the US Department of Health and Human Services discuses their recommendation for a telephone script on their site.

Just based on my initial search, my recommendation would be to suggest your patients use all their local pharmacy has to offer, including their version of refill reminders. Hopefully your patients have Internet access; otherwise some pharmacies may offer an automated telephone reminder as an alternative. If your patients can afford a bit more, then perhaps considering one of the private companies might be an option.

As our population ages, I suspect this will soon be built in to many services offered at no cost to patients because in the end the cost is so much higher when medications are missed. Truly when you think about it, we just can’t afford not to do this for everyone.