Access to a pharmacy is one barrier

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. About a third of patients who leave the emergency department never have their prescriptions filled. For help understanding why and what can be done about it, I'm speaking with Dr. Greg Conners. He's professor and chair of pediatrics and the executive director of the Upstate Golisano Children's Hospital. Welcome back to "The Informed Patient," Dr. Conners.

[00:00:33] Greg Conners, MD: Oh, thanks. I'm glad to be with you.

[00:00:35] Host Amber Smith: Let's begin by talking about the reasons so many people don't fill their prescriptions after they're discharged from the emergency department.

[00:00:43] Greg Conners, MD: Sure.

[00:00:44] Host Amber Smith: How often Is it because of the cost of the medications, or because the family lacks insurance to help pay?

[00:00:52] Greg Conners, MD: Yeah. That would be nice to be able to just tell you. It's a certain percentage, but that's a hard thing to figure out. What several researchers have done is looked into why it is that about one third of people who leave the emergency department, or in our case, the pediatric emergency department, don't end up filling their prescriptions. And it turns out to be a complex and thorny problem.

Certainly the cost of the medications and the lack of insurance is one factor. But probably a bigger factor is the access to a pharmacy. And the combination of that and sort of the logistics of getting to the pharmacy if it's night or evening and maybe pharmacies aren't open or as available as they could be. So while cost is part of it, there's actually quite a bit more to it than that.

[00:01:36] Host Amber Smith: So cost, and then the ability to get to a pharmacy, whether because of time of day or because of transportation. Do you ever see situations where the family doesn't seem to understand that the medicine's important and they need it?

[00:01:50] Greg Conners, MD: Sure. Yeah. And I'm just picturing someone who's been in the emergency department for several hours. It's, let's say, 11 PM. They're there with their child. Maybe they have two more at home. And what's on their mind when they're finally done? Not going to the pharmacy. I mean, sometimes it is. But sometimes it isn't. Sometimes it's getting home, getting the child in bed, taking care of the other kids. And so the pharmacy visit becomes kind of important, but less important. So it can all factor into why a medication ultimately doesn't get picked up.

But do people have a problem finding a pharmacy that's open? Absolutely. The 24/7 pharmacies are really getting fewer and further between. And I'll tell you the truth also, when we prescribe medication, we don't always know the hours in which the pharmacy's going to be open.

As far as prescribing from an emergency department, here at Upstate and actually across New York State, almost all of our prescribing is done electronically, so through the computer. And it doesn't automatically tell us what the hours of operation are for the pharmacy on the other end. So sometimes we have to ask the family's advice or we have to call the pharmacy and find out their hours. Or sometimes we just do our best.

[00:03:01] Host Amber Smith: Can providers accurately predict which families will or will not fill prescriptions, or do you just sort of not have any idea?

[00:03:09] Greg Conners, MD: Well, it's the subject of research. People have tried to find factors that are predictive of that, and it's actually pretty hard. Some factors have been associated with it, whether it's families with other children, or younger kids who have been in the emergency department a long time.

Sometimes language has a role, so someone who speaks a language other than English. We do really well with interpreters, and yet still, sometimes something is lost, or the understanding isn't quite there.

If it's late at night, as I mentioned. Of course, if people have not picked up their medications in the past, that's another sort of sign that it might not happen again. Or they don't seem to agree with the plan, as you alluded to, and we'll talk more about that. Or they, maybe they just don't understand the plan.

There's actually been research that unaccompanied teens maybe who are there on their own aren't always as reliable in picking up medications that are prescribed as other patients are.

So lots of factors. But in the end it's very hard to predict who does and who doesn't pick up their medications. So, we have to be, we in the emergency departments, have to be somewhat proactive and ask, "Are you going to be able to get this medication? I want you to know it's important." And physicians, but also a lot of us falls to nurses, but hopefully somewhere in the team, we make sure to ask families that. And if we only ask families that we think are high risk, we're going to miss a bunch. So we have to be pretty universal about bringing this up with everybody. Families sometimes don't understand why we're prescribing medications, and so we do have to reemphasize that as part of the touching base with families about why the medications are important.

[00:04:47] Host Amber Smith: You mentioned the electronic prescribing. Does the pharmacy alert you when the person picks up their prescription?

[00:04:55] Greg Conners, MD: No. There really isn't much in the way of feedback. When we hear from pharmacies, it's usually when there's a question, whether it's an insurance coverage question or the family doesn't think this is what they expected to pick up, something along those lines. And that's really actually a pretty small percentage of the prescriptions that we write. So most of the time we aren't alerted that a family did or didn't pick up a prescription.

[00:05:19] Host Amber Smith:

So let me talk to you about the dangers of not filling a prescription. What sorts of things could happen to a patient with certain conditions that doesn't get the medicine?

[00:05:31] Greg Conners, MD: I kind of, when I think about that, I kind of break things up into two categories. One is chronic conditions. For example, a child with asthma who has asthma now, and is going to continue to have asthma or who has seizures, or maybe diabetes, somebody who needs chronic medications to stay on track and to stay healthy. If they go without their medications, then their chronic problem, which might be well controlled, would be less well controlled, and they might end up having more seizures, or their blood sugar goes out of control, or they have trouble breathing from their asthma because they didn't pick up their medications.

Then there are the acute things. For example, if someone comes in with an infection, let's say ear infection or something else, as an example. This isn't a chronic condition, but at the time it's an important health problem for them. And whether they pick their medications up or not, it's going to make a big difference in if the acute infection or the acute problem gets better.

[00:06:23] Host Amber Smith: So they may leave the emergency department feeling better and thinking, oh, I don't really need that, but they do. The infection is still there.

[00:06:30] Greg Conners, MD: It happens, yeah.

[00:06:32] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with pediatrician, Greg Conners, the executive director of the Upstate Golisano Children's Hospital. Dr. Conners also leads the department of pediatrics, and he's a professor of emergency medicine and public health and preventive medicine.

Now, Dr. Conners, you're chair of the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, which has a report published in the journal, Pediatrics that gives some suggestions for how to increase compliance with filling these prescriptions. Can we go over some of the potential solutions?

[00:07:10] Greg Conners, MD: Sure, let's do it. I just want to just point out that this technical report that we published just this month of June in 2023 is really a wonderful resource for emergency department leaders who are thinking about dispensing medications from the hospital at the time of discharge in the emergency department.

And it's quite a balanced report. I think it talks about pros and cons, issues and things that a leader should think about. So I think that's really well done. And I'm saying that because -- although I am the committee chair, I'm not the principal author -- and I do really do admire the job that the principal authorship team did in producing this document. And it's available from the American Academy of Pediatrics at the Pediatrics Journal website.

[00:07:55] Host Amber Smith: So is it essentially suggesting that hospitals become pharmacies of their own, and they dispense the medicine to the patient before they leave?

[00:08:04] Greg Conners, MD: Actually this doesn't make any recommendations for or against. It mostly talks about factors that go into making such a decision. I think what it does is, it increases awareness. But this is something that is on the table. It can be done. If you hadn't thought of it as an emergency department leader, now you can think about it. Or if you're thinking about it, but don't really know enough by the time you read this technical report, you have a lot of information and also a lot of additional resources.

Of course it is something that many emergency department leaders have thought about, and yet this, for the pediatric leadership, it helps really frame some of the thinking. But I will just tell you that the report falls short of mentioning or recommending you should do this or you should do that. It's mostly an informational type of report.

[00:08:51] Host Amber Smith: Are there existing barriers to prescribing medications from the emergency department?

[00:08:58] Greg Conners, MD: Well, the short answer is yes. And the long answer is, I'm going to tell you more about what some of those barriers are. And there are several, quite a few, and it often boils down to money.

Sending patients home with prescriptions, I mean, it sounds wonderful, and it would be great if families could just get everything they need and then leave. It does require a lot of additional infrastructure from emergency departments, pharmacists, for example, to prepare the medications, to label them properly, all the things that a pharmacy will do when you go there, to explain, to think about billing and financial considerations for medications also. This is what a pharmacy is really good at. This is what they do. And so we would be required to be just as good at it.

A lot of hospitals -- for example, Upstate -- has an outpatient pharmacy. And so it's really nice if the pharmacy is open. And while we maybe can't send patients home with the medication right in their pocket, we can say, "and there's an outpatient pharmacy that's just wonderful, just around the corner and down the, within our same building. And if you'd like, we can send your prescription electronically to that pharmacy. They can start preparing it, and you can just go over and pick it up." That's really a wonderful option that we have. Not all emergency departments have that, but we do at Upstate. Of course it has limited hours.

Some additional considerations include the fact that when you're in an emergency department, you want to leave, and if it takes extra time to prepare and then dispense the medications, that can slow things down and sometimes present a barrier also.

And of course, we in the emergency department have a limited number of rooms, a limited amount of space. We want to get patients out safely and not in any way too fast. But once they're ready to go, we want them to be able to leave. And sometimes this can slow down the works. But there are lots of pros too. Those are some of the cons.

[00:10:53] Host Amber Smith: Let me ask you what Upstate is doing to help solve some of this.

[00:10:58] Greg Conners, MD: So in the Upstate emergency department, of course, we're subject to New York State regulations, which really limit the availability of filling outpatient prescriptions in the emergency department setting. Although we do have some ways of getting around things. And so for example, what we can do is give a first dose of, let's say, an antibiotic, right in the emergency department. And if it's an every eight hour medication or an every 12 hour medication, then the patient has eight or 12 hours before the next dose is due. And that may make the difference, and often does, in giving families time to get to the pharmacy, let's say, the next morning, and yet not missing a dose. So it's really nice that we're able to do that. And I will tell you, I've worked in other emergency departments where we haven't been able to do that. You know there have been rules against it or so forth. So it's nice when we can give the first dose. Also sometimes we will use a, let's say, an asthma inhaler with the patient, and then no one else is going to use that inhaler, so we can give it to them to go. That's sometimes available too. But there are New York State regulations, as I said, that limit the availability of using the emergency department as a distinct pharmacy. And it's something that actually our Upstate pharmacy leadership -- and I have to just say that our Upstate pharmacy leadership and our Upstate pharmacists are really a wonderful bunch, well educated, wonderful about being flexible. I always have great admiration and appreciation for those folks -- so we have some of our leadership working at the state level to try to get regulations updated, upgraded to be more what we would consider patient friendly.

I will just tell you that we also keep in mind that every time we dispense something, that's a pharmacy in town that has one less opportunity to dispense something. And I would hate to have a pharmacy no longer become a 24-hour pharmacy because we've sort of taken over giving their nighttime medications, if you see what I mean, providing too much competition, so that's no longer economically feasible for them to stay open all night. So all that goes into the thought about whether or not we should be prescribing medications on discharge from the emergency department.

[00:13:13] Host Amber Smith: So this report is a roadmap, essentially, to other children's hospitals for how to do this maybe more efficiently than they're doing it now?

[00:13:21] Greg Conners, MD: Sure. Yeah. I like to think it'll be really helpful to people who haven't given this as much time and research as it really requires. And so the authorship group got together and put a lot of time into making as comprehensive as they could.

[00:13:35] Host Amber Smith: Well, Dr. Conners, thank you for taking time to tell us about it.

[00:13:38] Greg Conners, MD: Oh, I'm happy to do that. Thanks.

[00:13:41] Host Amber Smith: My guest has been Dr. Greg Conners. He's a pediatrician and executive director of the Upstate Golisano Children's Hospital. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.