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The Pill Burden of Chronic Disease

 , January 14, 2014

A pill box of a patient with multiple chronic conditions

The pill burden of chronic disease – the last mile problem in chronic disease management?

We all have patients whose primary complaint is, “Doctor, do I really need to take all these pills? Can you tell me which one to take at what time? Which ones should I avoid taking together?” 

As our population ages and we treat acute diseases better, we are facing a huge burden of chronic diseases.  As primary care physicians we manage patients with multiple conditions like diabetes, coronary artery disease, ischemic cardiomyopathy, impaired renal function, hypertension etc.  As we provide “evidence-based” care to our patients, they end up on a large amount of medications to be taken on a daily basis.  We are aware of this as we look at their medication lists in our electronic health records, but recently an elderly patient shared with me images capturing the weekly process he goes through of filling his pill boxes.

The steps are as follows:
  1. Collect the pill bottles and medication blister packs for all the prescribed medications
  2. Use a pill box that has 4 compartments for each day of the week
  3. Systematically take each medication and based on dosing fill out the compartments for the whole week.  He has 26 pills that he takes each day, distributed between the 4 compartments for that day.  This totals up to over 180 pills for the week that he has fill into his pill box.  This is a critical step as he needs to recognize each tablet and remember the dosing for each one.  Since he has an early cataract he has a hard time reading the fine print and goes mostly by the color of the pill or the packaging.  If there is any change in these, there is a huge risk of an error.
  4. Throw away the empty blister packs and containers.

empty blister packs

While this sounds simple enough, the process takes him about 40 minutes each week.  He does the same for his wife who is not capable of doing this herself.  

The photographs capture much better than words the complexity of this task.  As we look at our growing disease burden, we should keep in mind the pill burden faced by our patients.  It becomes our responsibility to ensure that they are not being prescribed unnecessary medications or potentially dangerous regimens.  Our colleagues in the pharmacy side should explore the best way to dispense these medications to patients who cannot go through this onerous and complex task independently.  This is even more challenging for our sicker patients who are seen in many setting by various providers and undergo frequent medication changes.  

Prescribing medications is one of the key interventions we do for our patients.  While we work on improving various processes using quality improvement methods, we may not see a significant improvement in outcomes till we solve this last mile problem of getting the right medication into the patient at the right time.