Welcome to the "People Always, Patients Sometimes" podcast, a production of Spencer Health Solutions. Healthcare has come to a crossroads and it's time to start listening to new ideas. That challenge is the 'always done it that way thinking' We hope you enjoy our conversations with the disruptors, the innovators and the transformers in clinical trials and healthcare.
For this podcast, we've invited some special guests in recognition of Heart Failure Awareness Week to discuss the serious impact cardiovascular disease has on our lives. With us is Herb Patterson, PharmD Professor of Pharmacy and Research Professor of Medicine at the UNC Eshelman School of Pharmacy and the interim chair of the division of Pharmacotherapy and Experimental Therapeutics. Dr. Patterson is also a board member of the Heart Failure Society of America. Betsy Whitmore is from UNC REX Healthcare is the Regional Practice Administrator of the REX Cardiac Surgical Specialists, the REX Structural Health Clinic and REX Heart Failure Readmission Clinic. She is also a Cardiovascular Clinical Nurse Specialist.
Janet Kennedy (01:00):
We've invited a couple of members of our team here at Spencer Health Solutions to be in the discussion. With us is Tom Rhoads, CEO, and founder of Spencer Health Solutions. Also with us is our Chief Scientific Officer, Alan Menius. Tom, what are we going to be talking about today?
Tom Rhoads (01:19):
Thanks, Janet. We’ve all known for a long time how serious a problem we have in the U.S. with cardiovascular disease. It’s our leading cause of death: One out of every four deaths is the result of heart disease. Beyond the human toll, the financial burden amounts to $219 billion each year, according to the CDC. This month is American Heart Month, so we’ve brought all of you together to talk about heart disease. Since this week is recognized as Heart Failure Awareness Week, we’re going to spend a lot of time discussing that topic. Let’s zero in on heart failure. It’s one of the most common and difficult conditions in the United States, affecting about 6.5 million people over the age of 20. Unfortunately, it's a disease that's growing. About 960,000 new cases each year are being diagnosed, according to the Heart Failure Society of America. We know a lot about heart failure and how to treat it. We know it occurs when the heart can't pump enough blood. We know it's a progressive disease. We know it can be treated with lifestyle changes, medications, and in some cases, surgery. But sometimes in health care, simply knowing isn't enough. Despite the body of knowledge we have, and the effective treatments available to patients, they sometimes have trouble making those lifestyle changes. And taking their medicines.
Janet Kennedy (02:29):
All right. This is going to be a great discussion, I can tell. Let me take a minute to ask our two guests to tell us a little bit about themselves and their background. Betsy, welcome to "People Always, Patients Sometimes". We're so glad to have you here today.
Betsy Whitmore (02:43):
Thanks so much. I am a nurse by training and I've been in healthcare in cardiovascular mainly for the last 41 years. I have worked in cardiac surgery as a staff nurse and educator and administrator and I have been at UNC REX Healthcare for most of the last 20 some years and about two years ago I took over the heart failure readmission clinic in addition to my other practices and with the clinic, I work with two physician providers, two advanced practice providers, some wonderful office staff and nurses to provide the best care that we can for our patients at UNC REX.
Janet Kennedy (03:23):
I always wonder how you get everything done with so many titles, so many responsibilities. That's kind of crazy, but I think we're going to be really looking forward to a lot of your different experiences from the administrative side and also a former, well, I said former earlier and you corrected me. You are an active licensed nurse right now, is that correct?
Betsy Whitmore (03:40):
That is correct.
Janet Kennedy (03:42):
Well, we're going to enjoy your input and your ideas here this morning. Herb, welcome to "People Always, Patients Sometimes." Glad you have you here today.
Herb Patterson (03:50):
Thank you so much. Yes, as you mentioned, I'm a faculty member at the University of North Carolina Eshelman School of Pharmacy, pharmacist by training, but I have spent pretty much my entire professional life dedicated to either the clinical research or the clinical care of patients with heart failure.
Janet Kennedy (04:07):
All right, and let's meet our Spencer Health Solutions team. Our Chief Scientific Officer is Alan Minus and he comes to us from Glaxo Smith Kline and other pharma and healthcare organizations. Alan, tell us a little bit about your background.
Alan Menius (04:21):
My background is in biochemistry and biostatistics. I spent 25 years at GlaxoSmithKline in all facets of research and development. Was fortunate enough to see several medicines go all the way front of discovery, all the way up to seeing patients and even got to do a lot in medical affairs where we got to actually work with physicians and understanding how the drugs were being used in patient populations. So that became a natural progression for me to go to a company like Spencer Health Solutions where we're actually working to really get into the homes of patients and provide them with technologies that really help with their care.
Janet Kennedy (04:53):
Also with Spencer is our CEO, Tom Rhodes, and he's actually been on a couple of podcasts recently for other people, but not on ours. So glad to have you here, Tom.
Tom Rhoads (05:03):
Oh, glad to be here. Janet.
Janet Kennedy (05:05):
Tell me a little bit about Spencer Health Solutions and how that plays into cardiovascular disease.
Tom Rhoads (05:12):
You know, at Spencer Health Solutions. We are really focused on bringing a direct-to-patient platform into the home so that we can address some of these very complex diseases and in many cases, chronic diseases. That platform has really taken shape where we've seen really unprecedented results from our engagements with patients in their home over the last three years with greater than 97% adherence and 81% engagement across the population. So it's exciting to see the team's effort to help these patients live longer and more productive lives.
Janet Kennedy (05:42):
Well, let's start our conversation off and really ask the big question. What is the biggest challenge that you're currently seeing in treating cardiovascular disease? Herb, I'm going to ask you first, what do you think?
Herb Patterson (05:55):
Well, first of all, thank you for pulling this together and inviting me to participate in especially during Heart Failure Awareness Week. As I mentioned, I'm a big proponent of the Heart Failure Society of America, so I hope that the listeners will go to the hfsa.org website and take a look at everything that the society has to offer. To me, the biggest problem is pretty simple. It's getting the right drugs at the right doses to heart failure patients. I'm focused on the heart failure part of this and I've had the good fortune of working on a registry study of the last four years called the CHAMP HF registry. And designed this so that it could take a contemporary look at how heart failure patients were being treated with the pharmacotherapy.
Herb Patterson (06:38):
And I think most of us felt like when we started that we were probably doing a pretty good job of treating patients because we have all the guidelines that are out there, the clinical trial data that support the drugs that we use, but it was pretty amazing. Sort of the first look at the data that was published in the Journal of the American College of Cardiology in July of 2018 showed it only about 73% of patients were on either an ACE inhibitor or an ARB or now the new RNE agent, only about two-thirds were on a beta-blocker and only about one-third of the patients who are on mineralocorticoid receptor antagonists and that was just being on the drugs and when you looked at whether they were at what we call target doses, which is the dosing concept that we use in heart failure, only 1% of the patients were on the right drugs at the right doses, only 1%. We clearly have a lot of work to do to improve that.
Janet Kennedy (07:32):
Why is that? Why were only 1% on the right doses?
Herb Patterson (07:36):
I'm not sure if it's because the message is not getting to the healthcare professionals about what are the right drugs that should be used. And I think part of that is if you look at especially heart failure cardiologists and even cardiologists, they do a pretty good job, you know? But a lot of heart failure patients are taken care of by family practitioners, by internists, by hospitalists. And I'm not sure that they are as familiar with the data as some of the other healthcare professionals. So I think that's one thing. And the other is that there are adverse effects associated with some of the medications. And so a lot of times the healthcare professionals, prescribers don't want to get into that part of it. There's dose titration that's required, so it's not a simple thing to do, but the data are so strong to suggest that patients should be on these drugs at these doses.
Janet Kennedy (08:24):
I can see a much deeper conversation here, but I'm going to pop over to Betsy and ask from your perspective where you're dealing on an administrative level with the individuals who are doing the direct care with these patients, what kind of challenges are you seeing from your perspective?
Betsy Whitmore (08:40):
Well, I think even as an administrator, I still probably think more like a nurse than I do as an administrator. So I think of this morning, I think probably down at the granular level and for us taking care of these patients, it's, and this is a very overused phrase, it does take a village to take care of these patients. There are so many aspects of dealing with patients that have a chronic disease. It involves social work, it involves pharmacy, it involves nursing, it involves our physicians, it involves transportation. There are so many aspects that are required to make sure these patients get the correct care at the correct time and over a longitudinal basis.
Betsy Whitmore (09:17):
It's not just with my other practice, one of my other practices, which is cardiac surgery. Our patients are discharged after a two-week followup. If they're doing well, that's not a long-term relationship. These are long-term relationships we build with these patients and families. I mean, my staff sends sympathy cards to patients, our patients that pass away. I mean it's a family effort and it just becomes more and more huge every year with the number of patients. It's a growing, growing problem, with very little end in sight it seems.
Janet Kennedy (09:48):
Do you find that the patients you're working with as heart failure patients are different than other chronic diseases like diabetes?
Betsy Whitmore (09:57):
Well, I mean, my specialty obviously is all the cardiac folks. I have knowledge of diabetes and chronic obstructive pulmonary disease. And there's certainly some similarities in dealing with chronic disease and medication adherence and for COPD patients, oxygen therapy and all the things that go into that so I think there's definitely a lot of similarities. A lot of focus for most healthcare institutions are on COPD and heart failure as two targeted areas. I mean, those are two of the big ones where we see a lot of readmissions and need to make an impact. So I think there's definitely similarities for sure. There are always nuances in every specialty.
Janet Kennedy (10:33):
Well, let's talk a little bit about heart failure specifically, and there's no doubt that lifestyle changes in medications can be effective treatments and yet, Oh gosh, we're human, we're not very good about doing that. So what barriers do you see from the patient perspective and why are these changes so hard and how should they get more support from clinicians or health coaches or family members? And Betsy, you already started off addressing some of that. So let me start with you.
Betsy Whitmore (11:01):
Well, again, there are many reasons why people don't take medication. There are many reasons why people don't come for a followup visit. A lot of it is related to, not that they don't want to or not that they don't see the value in it. It's just life gets in the way. We have, as I'm sure many practices that deal with patients with chronic diseases. We have a fair no show rate for patients coming to follow up appointments. It gets very frustrating just on the face of it. You say, why didn't this patient show up? And many times they don't even call. We don't know till they don't show up that they're not coming. When we try to investigate it, it's I can't drive. I'm depending on my son. He couldn't leave his job today to drive me to my appointment. Did they think to call us about that in advance so we could maybe help them with that? Know a lot of people don't want to ask for help, particularly the elderly in some of our rural patients, very proud people. They don't want to ask for help. They don't want to tell us that they're having some of these issues or financial issues. So there are many reasons people don't take medicines, come to appointments or do what we in all our vast knowledge think that they should be doing.
Janet Kennedy (12:04):
And I know Herb, you're a data guy, so I'm curious to know, is heart failure something that impacts all races, all ages, all demographics, or are we seeing anything unique about heart failure patients?
Herb Patterson (12:17):
You're exactly right. It does affect males, females, all races, all different age groups. Although it is primarily a disease of the elderly. But no, it's multifaceted. And affects everyone.
Janet Kennedy (12:29):
So what kind of barriers from a pharmacy standpoint do you see in patients that have heart failure?
Herb Patterson (12:35):
Betsy has done a great job of summarizing that. Again, it's a complex issue. There are a lot of moving parts to it, especially though obviously I focus on the medication part and I think one of the issues in heart failure is that patients if we get them on the correct drugs, it is a fair number of drugs. We know that as you increase the number of drugs that are prescribed to patients, that adherence drops. So it's important to try to make sure you want to get them on the right drugs at the right doses. But you also want to make sure they're not on the wrong drugs as well. So sometimes there are drugs that can exacerbate a heart failure admission, like non-steroidal anti-inflammatory drugs, and so on. And the other point that Betsy made is that heart failure patients typically have a nHerbumber of comorbidities.
Herb Patterson (13:27):
It's not just heart failure, it's diabetes, it's C O P D, it's atrial fibrillation, it's hypertension and they're taking medications for all these different comorbidities, appropriate medications, so that increases the medication burden even more. And the other important aspect of those, as you increase the number of medications, you're also increasing costs. And even if all those drugs are on like the $4 list at Walmart or something, which they never are, it's still an expensive proposition and a lot of our patients and I'm sure Betsy's as well or perhaps lower-income patients who might not be able to afford that and so they have to make hard choices about what they can do and what they can't do.
Tom Rhoads (14:09):
Well, Tom, I know that we have talked a little bit about the importance in working with the elderly and making their health management as easy as possible. Do you see that confusion can play a part and is there a way for digital technology to help with that?
Tom Rhoads (14:25):
I think Herb and Betsy have certainly hit the bulls-eye here. It is a complex issue and technology can play an important role here. Just taking the pill burden that we were just talking about. As an example, we have a population that went back three years now that's averaging seven and a half meds per day and when you start adding titration schedules and generic switches and all those things in there, it's a heck of a burden to on an individual. I know to help my father who coupled type two diabetes, heart disease, and cancer together, he was on 12 meds per day and it was quite a burden for the family to deal with that. So I think technology does have a role. It's not the only aspect that it should be focusing on through care coordination, education, those aspects are critically important as we understand, of course, a financial burden, but being able to give the healthcare system visibility to those things and allow to kind of, I think as Betsy said, the village to come around you and help you and support you with coupons and other things that might be available. It starts with understanding what the situation is and then we can coordinate appropriately. I think tech definitely has a role. It's one of the things we've seen in some of the studies where just by being more adherent, you can reduce your mortality rate by over 10.6% based on American Heart Association study done a few years ago. So, it's well worth it, but technology has a responsibility to make sure it's easy to use and aligns with their lifestyles.
Janet Kennedy (15:54):
Alan, what about you? Do you have any thoughts on how either technology or adherence in heart failure is something that can be addressed?
Alan Menius (16:02):
I think several have brought up some really good issues. And the first one is the co-morbidity issue. As we look at our population and we look at how people are being prescribed medications, it's not just for one ailment, right? They're being going to one physician, they're being treated for say heart failure. And then they'll go home and they'll talk to another physician that will talk to them about their diabetes and they'll go to another physician and talk to them about maybe they have a CNS issue and then they're probably getting prescriptions for each one of those ailments. And I think a lot of the burden comes from them saying, okay, where am I gonna get these medicines? Am I going to go to grocery store A and then over to a pharmacy B and hope that I get the right things?
Alan Menius (16:40):
And finally who is taken care of to make sure that some of these medications are contraindicated. So in other words, they're taking a pill but it's actually not the type of thing they should be taking when they're taking this other pill. And so I think there's a real opportunity here to try to decrease the amount of medication burden in these people's lives. And the village concept is a really great one because you figure out how do you take away that burden of having to figure out which medicines to take when and making sure that that aspect of their lives is taken care of more. And technology has a great role to play here as well that connecting with these patients. Betsy brought up the great loss to follow up conversation, which is where these patients go, right? And the technology could have a great role to play here and just connect with those patients. Again, making them feel at ease that there is a connectivity between ourselves and the healthcare environment. So it really is kind of a very complex situation where we have some great medicines out there. We have a lot of great physicians out there, and great ways, paths forward to helping these people live with these diseases, but we have to use the technologies to make it really easy for them to comply.
Janet Kennedy (17:49):
Herb, what are your thoughts?
Herb Patterson (17:51):
Yeah, I just wanted to follow up on a very important point in down just made about [inaudible] and I'm a strong proponent of patients getting all their prescriptions at the same pharmacy. And I know a lot of patients will, will shop around and just because they sometimes can get a cheaper medication that pharmacy a but you know they get the rest of them at pharmacy B, but if they can get them all at the same pharmacy, that way the pharmacist gets to know them, they've got all their medications in front of them, they can identify a potential drug interactions, can help them with the pricing kind of things. So I think that's a very important concept and I think we need to get to the point where we can advocate for that as much as possible.
Janet Kennedy (18:31):
And what would you say are some of the more promising interventions that might help patients stay on their medications?
Betsy Whitmore (18:36):
I think you have to look at your patients specifically with some of our elderly patients. We do a lot of technology-related things like automated phone reminders and those types of things. And we found that more often than not, that actually confuses patients. They think when they're acknowledging, yes they're coming for their appointment, they actually cancel the appointment and they don't realize that and then they show up. They've been taken off our schedule because technically it was canceled. So I mean there are some interesting technological app type things out there, but for our elderly patient population, I mean they don't even use email. So those kinds of things. For a younger audience, I think apps are great. I mean I think there is a lot of things out there.
Betsy Whitmore (19:15):
We use them in my workplace to be part of our wellness program in order to get some discount on our health insurance. So we're all quite familiar with that in a healthcare setting. I think we have to be aware that not all of our population works well with something like that. I think it's always the personal touch. Our clinic nurses make followup phone calls, scheduled phone calls with our patients to touch base with them with a kind of set list of protocol questions to see how things are going. The personal touch always seems to me to be the best thing, but not always possible. Obviously.
Janet Kennedy (19:49):
Let's look ahead to the future here. What do you see coming down the pike five years from now that's going to make it easier for patients to manage with their heart failure and with a health organization to be able to support them?
Betsy Whitmore (20:02):
I think probably going more towards accountable care organizations and more coordination of care regardless of what your insurance is so that I think there is going to be more people involved in handling your healthcare so to speak because I think that for some of these chronic diseases, we know that there's a prescribed erode that's the best for most patients to go on and we're clearly not doing a good job of getting them on that road or keeping them on that road right now. So this is just guesswork on my part, but I think probably more management of those types of high dollar and very prevalent disease states.
Janet Kennedy (20:38):
That makes sense. Herb, what do you think? What's coming down the pike as you have seen the evolution of the pharmacist? At the table and the work that you are with your organization, what's coming up in five years?
Herb Patterson (20:50):
I think technology is going to continue to play an important role. There's a number of apps out there that may be able to help with adherence. One of the things that I think that we need to do is that we have to get the community pharmacist more involved in taking care of these patients. It's hard for patients to have access sometimes to the major medical centers, academic medical centers and so on where they get superb care, but they all have access to their community pharmacy. And again, because a lot of optimal care of heart failure patients, the right drugs at the right dose, I think pharmacists can help with that. Working with their nursing and physician colleagues as a backup. That's where I would like to see this go because I think if we could get them involved, and it's not just, again, not just heart failure, I'm not isolating heart failure, but it's diabetes, it's all the comorbidities and stuff too. So I think if we could get to that point, I think it would make a huge impact on heart failure patients.
Janet Kennedy (21:46):
Alan, if I asked you to put on your prognostication hat and look down the pike as a scientist, what have you seen change in the last five years that might impact what's coming up in the next five?
Alan Menius (21:58):
Well, a couple of things. The first one is personalized medicine, and I know that's a buzz word that people throw out a lot of times, but it really is this idea that as more and more information becomes available to be used and treatment of patients, whether it be genetics, whether it be social-economic factors, we'll know a lot better about how to tailor a treatment regimen to a patient, even with one or more diseases. And that's one of the most important things. What that does though, if you think about it, it actually creates even more complexity for a patient. You might have the ability to have this customized treatment path for everyone, but who's going to make sure that that's followed well? How do you make sure that this custom made treatment that's going to have hopefully much better outcomes will be actually used inside the home of the patient. And so all these things we're thinking about, the technology is going to be great. The newer medications are going to be there but actually means we need to up our game with how we actually treat patients in the home and use technologies and make sure we aid them to follow that new treatment path.
Janet Kennedy (22:54):
Herb, you had something to add.
Herb Patterson (22:55):
Thanks so much for bringing up the whole personalized medicine individualized therapy kind of thing. Cause I really do believe that is the future and especially with heart failure because the way that we treat heart failure now we just keep adding drugs, but we know that not all patients respond to an ACE inhibitor and all patients respond to a beta-blocker or an MRI. So what we have to do is we have to figure out either through pharmacogenomics or some tool, we have to figure out which of those drugs are going to be most effective in those patients. And by reducing that medication burden, we decrease costs, we decrease the number of adverse effects, we improve adherence hopefully. So I think that's really where we have to get. And the other piece of that is the dosing part where we've traditionally used target doses, but now we know that it's just counter-intuitive to think that all patients, no matter what their size, no matter what their age or anything, should take the same dose of a drug. And so we've got to figure out, and I guess to your point about tailoring the dosing, but then making sure that we can get those individualized doses to the patient and it's just going to get worse because there are several new heart failure drugs that are in clinical trials that look promising. So if they come out, we're going to add those to everything else. So it's a huge issue. But personalized medicine I think is where we need to get.
Tom Rhoads (24:18):
Herb. I think you're right on. You know, it's interesting to see if we look out five years where we are today and where we'll go. Technology has a huge role to play. One of the leading things I think we'll see is artificial intelligence being applied to some of these complex issues so that we can be more proactive as a community. We obviously have, especially with primary care physicians a shortage that we're trying to address. We need more touchpoints. I think community pharmacy is an excellent role. I believe there was a study that was done that shows that on average people go to the community pharmacy about 35 times a year. If we think in terms of the engagement with the health center, even with the heart failure patient, I'm going to take a guess, but I'm guessing that's probably no more than eight times a year, maybe even not that much.
Tom Rhoads (25:02):
So if you think about just access and opportunity, being able to bring that back to the home from a technology standpoint and being able to basically engage with someone on a daily basis to make sure in this case there are personalized medicines being adhered to, that there aren't any unforeseen side effects, where we're care coordinating. And probably most importantly as we look at AI, we're able to begin to proactively or prescriptively manage their healthcare. So I think it's a really exciting time that we're in right now where it's all coming together. I think with leaders like REX and UNC, I'll throw one in from my Alma Mater, Duke (couldn't resist), but I just think there's a lot of really deep thought around this issue and I'm excited to see where we go.
Janet Kennedy (25:45):
This has been an excellent conversation and I thank you all for being here. Herb Patterson with the UNC Eshelman School of Pharmacy, Betsy Whitmore with UNC REX Healthcare and our own Spencer Health Solutions', Tom Rhodes and Alan Menius. I really appreciate you all being here and helping us really explore the idea of heart failure, cardiovascular disease, and of course celebrating that this is "Heart Failure Awareness Week". You've been listening to "People Always, Patients Sometimes", and we thank you very much for your time.