1. Wisconsin Health Literacy Conference Keith W. Trettin R
Wisconsin Health Literacy Conference Keith W. Trettin R.Ph;, MBA Program Manager (Retired) VA National Center for Patient Safety
PROJECT DESCRIPTION
Use an evidence-based, patient-centric evaluation model to determine preference for a standardized national VA prescription label which enhances Veteran comprehension and satisfaction over current VA prescription labels.
Rx#
Patient Name
Patient Name
Rx#
One Label
One Mission
One VA
Rx#
Patient Name
IOM
2006
ACPF
2006/2007
VA NCPS
2007
NABP
2008/2009
USP
CA Senate Bill 472
AFB
2008

3. 644 Cases involving Rx + label 2000-2011
NCPS Database
644 Cases involving Rx + label
DOD 2659 Cases of OP Mislabeling Event Reports. FY09-Sept 11.
“Glyburide 5mg tablets take two tablets by mouth twice a day ( half an hour before a meal )” . Prescription written for glyburide 10mg BID AC. Patient misunderstood directions and was taking his glyburide before every meal three times a day resulting in hypoglycemia. Label changed to read twice a day half an hour before breakfast and dinner.
"Take one tablet by mouth every day for heart give x 2 doses only (start 8 hours after the initial 250mcg now dose is given). Asked pt how he was taking his digoxin and pt reported "twice daily just as the label says".
1229 Cases involving ½ tablet incidents
“Take one half tablet daily for blood pressure”. Pt called the pharmacy stating he would run out of lisinopril before the refill date. The prescription was for lisinopril 10mg tablet, In talking to the pt it was found he had been taking a whole tablet instead of splitting the tablet and taking only one half daily. The pt was instructed to take just half of the tablet for each dose.

4. VA Rx Benefit!
24 Million Vets in 2013, 4.87 Million users of the RX benefit. DOD 7.1 M
136 Million RXs were filled by VA Pharmacies 4%/yr 60M in 1995.DOD 133 M
142,986,291 OP Rx filled in FY13 at a cost of $3.3 Billion
CMOPs filled 77% of all Rxs DOD8%
7,276 Pharmacist and 4,149 Pharmacy Techs are employed by VA.
VA Rx labels are not standardized.

5. Health Literacy, and Prescription labels, Why should we be concerned?
12% of adults have proficient health literacy and can interpret a Rx label correctly! AHRQ Pharmacy Health Literacy Center
30% of patients inadequate health literacy were able to state how many pills of a prescription should be taken. *
54% of patients can interpret primary label Wolf, et al. Ann Intern Med 2006
75% of patients with inadequate health literacy were able to correctly state how to take a medication four times a day!*
*Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995; 274:

6. 446 Veterans at 11 Survey Sites & 697 Pharmacist/ Technician Participated

7. TYPICAL VA Prescription Label
Refill number
Pharmacy name & phone #
“Fill Date”
Rx #
Aux Info
Patient name
Directions for use
“Use by” Date
# Refills
Drug Qty
Product Description
Drug name
Prescriber
Fed/State Cautions
66% of respondents were satisfied with their current label!

8. % VETERAN IMPORTANCE OF LABEL INFORMATION
Not Important 2 3 4
Very Important
Dosage instructions 1 9 88
Drug name 10 85
Veteran’s name 6 7 83
Fill number (2 of 3) 16 72
Number of refills left 18 71
Rx number 11
Quantity of pills 21 63
Filled date 20 62
VAMC phone number 61
Discard date 12 55
Written warnings (take w/food, etc.) 5 15 22 54
Doctor’s name 52
Description of pills (shape, color) 8 14 50
VAMC facility name 13 46
Pictures (relating to take w/food, etc.) 17 37

9. WHAT VETERANS IDENTIFIED AS MOST IMPORTANT
Refill number
Pharmacy name & phone #
“Fill Date”
Rx #
Patient name
Aux Info
Directions for use
“Use by” Date
# Refills
Product Description
Drug Qty
Drug name
Prescriber
Fed/State Cautions

10. WHAT PHARMACY STAFF IDENTIFIED AS MOST IMPORTANT
Refill number
Pharmacy name & phone #
“Fill Date”
Rx #
Patient name
Aux Info
Directions for use
“Use by” Date
# Refills
Product Description
Drug Qty
Drug name
Prescriber
Fed/State Cautions

11. Vets Don’t read the Rx label Everytime
VETERANS REFERENCED INFORMATION ON THE PRESCRIPTION LABEL
Never
Once
Sometimes
Every time
Drug name 1%
10%
17%
72%
Instructions
27%
55%
Veteran’s name 4%
25%
15%
56%
Doctor’s name 8%
28%
29%
35%

12. Test Your Knowledge Chew before swallowing Do not refrigerate.
Tell what this picture means.
Tell what this picture means.
Chew before swallowing
Do not refrigerate.
Veterans rated pictures as the LEAST Understood & LEAST Important part of the Rx label.
Tell what this picture means.
Tell what this picture means.
Dissolve in full glass of water.
Avoid the sun while taking this medicine.

13. Test Your Knowledge How many do you take in a day?

14. If you said “1” you and 42% of Veterans Answered Correctly
NUMBER OF PILLS IN 1 Day
% of respondents
One
42%
Two 3%
Three
38%
Depends on how many meals I eat
13%
Don’t know 4%

15. Numeracy Number of pills in one day
TAKE 1 TABLET BY MOUTH IN THE MORNING AND EVENING 89%
TAKE 1 TABLET BY MOUTH TWICE DAILY – %
TAKE 1 TABLET BY MOUTH TWICE DAILY WITH FOOD – 85%
TAKE 1 TABLET BY MOUTH ONCE DAILY WITH FOOD – 81%
TAKE 1 TABLET BY MOUTH ONCE DAILY WITH MEALS - 75%
TAKE 1 TABLET BY MOUTH TWICE DAILY WITH MEALS 75%
TAKE ONE TABLET BY MOUTH DAILY WITH MEALS – %
70% of Rx staff preferred using “food”

16. The words we use make a difference to the Veteran!
NUMBER OF PILLS
% of respondents
One
42%
Two 3%
Three
38%
Depends on how many meals I eat
13%
Don’t know 4%
NUMBER OF PILLS
% of respondents
One
81%
Two 8%
Four 4%
Don’t know 7%

17. MEALS WITH WHICH TO TAKE THE MEDICATION
What does meals mean?
MEALS WITH WHICH TO TAKE THE MEDICATION
Veteran %
Rx %
With 2 meals
Breakfast and supper
68%
88%
Breakfast and bedtime snack 6% 2%
Lunch and supper 5% 1%
Breakfast and lunch 4%
With 1 meal
Breakfast only
1% (2Rx,2T)
Supper only 3%
Lunch only
Bedtime snack only
With 3 or 4 meals
Breakfast, lunch and supper
3% (5Rx,12T)
Breakfast, lunch, supper and bedtime
3% (7Rx, 10T)
Don’t know

18. More words do not always increase understanding.
Prescription label
Grade level to understand*
Take one capsule by mouth three times a day for pain.
1.5
Take one capsule by mouth three times a day for pain and spasticity.
4.9
Take one capsule by mouth three times a day for pain and spasticity. (Approved by Chief of staff)
6.5
Take one tablet by mouth at bedtime and take one tablet at bedtime as needed.
5.9
Take one tablet by mouth at bedtime and take one tablet at bedtime as needed for depression & mood.
7.8
* Flesh-Kincaid Grade Level as determined by Microsoft Word® Version 2007

19. USABILITY Larger font is preferred
PREFERRED LABEL FOR INSTRUCTIONS
% of respondents
A much easier
69%
A a little easier
10%
A and B are equal
12%
B a little easier 4%
B much easier 5%

20. USABILITY Veterans prefer bolded sig:
PREFERRED LABEL FOR INSTRUCTIONS
% of respondents
A much easier
14%
A a little easier 7%
A and B are equal
31%
B a little easier
16%
B much easier
32%

21. USABILITY Vets prefer selective highlights
preferred label for instructions
% of respondents
A much easier than B
29%
A little easier than B
12%
A and B are equal
33%
B a little easier than A
10%
B much easier than A
16%

22. How we ask a Veteran to take ½ tablet makes a difference
How we ask a Veteran to take ½ tablet makes a difference! 8 Million Rxs/Yr
TAKE ½ (ONE-HALF) TABLET BY MOUTH… 88% gave the correct response.
TAKE ONE-HALF TABLET BY MOUTH… %
TAKE ONE-HALF (12.5 MG) TABLET… %
TAKE ½ TABLET BY MOUTH … % .

23. ½ Tab Education Differences
People with educations of some college or more were more likely than those with educations of high school or less to respond correctly to these questions:
Take ½ (one half) tablet by mouth in the morning and the evening (92% vs. 78%) P=.001
Take one-half tablet by mouth in the morning and in the evening (93% vs. 74%) P=.001
Take one-half (12.5MG) tablet by mouth in the morning and in the evening (88% vs. 71%) P=.001
Take ½ tablet by mouth in the morning and in the evening (86% vs. 66%) P=.001

24. Highlighting & bolding of patient centered info
VA PATIENT CENTRIC PRESCRIPTION LABEL, PREFERRED BY VETS AND PHARMACY STAFF
Patient name
Aux Info
Directions for use
“Fill Date”
Drug name
“Use by” Date
Rx #
Product Description
Prescriber
Pharmacy name & phone #
Drug Qty
Fed/State Cautions
# Refills
Avoid jargon
Use ½ (one half)
Highlighting & bolding of patient centered info
Sans serif, min. 12 pt font

25. The VA is not the first to adopt a Patient-Centric Prescription label
The VA is not the first to adopt a Patient-Centric Prescription label. Let us not be the last!

26. Questions?
Keith W. Trettin, RPh