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packaged this way. We're the last major holdout, with cost often cited as the reason. But a comparison of pack- aging tablets in bottles versus blisters yields a surprising result. The breakpoint in the cost of using either package is almost always 30 to 40 tablets (or capsules), so let's use 35 tablets for comparison. Thus, if the package will hold fewer than 35 tablets, then a blister would be less expen- sive. If it will hold more than 35 tablets, then the bottle is less expensive. It's interesting that the breakpoint is about equal to the number of days in a month. That means, by using blis- ters, you could establish two benefits in treating chronic conditions. First, people would know when and whether they took their medication and, second, when patients either do or don't refill their 1-month supply, the phar- macist and physician can tell how well patients are fol- lowing the prescribed course of treatment. In addition, because of how the information would be gathered, there would be few concerns about privacy. Those concerns are more likely to arise with internet-enabled devices that record behavior. It's surprising that better packaging isn't promoted more by healthcare professionals, government adminis- trators, and insurance companies. The VA conducted a very compelling study on how adherence-focused pack- aging improves patient outcomes [2]. Conducted at Walter Reed Hospital in Washington, DC, and known as the Federal Study of Adherence to Medications in the Elderly (FAME), the study tracked adherence of patients with high blood pressure and/or cholesterol. The results showed that the blister packaging led to a remarkable 97 percent increase in adherence after 6 months. The pack- ages in the study went a little further than ordinary blis- ters, and included all the patient's tablets/capsules in one blister cavity, with each cavity labeled by day and time. This type of packaging may be the next step to improve outcomes in the treatment of chronic conditions. Already, many online pharmacies bundle multiple med- ications in a pouch or blister and label them clearly for patients. This kind of bundling is a big advance over the pillboxes that require people to remove their medications from the original packaging and drop them into a cavity— one for each day of the week—to track when to take their meds. But since pillboxes don't specify the time of day to take the medications, they provide little help to people who take multiple medications throughout the day. There are also electronic options, such as bottle caps that flash or emit a sound to remind people to take a tablet and then record when the bottle was opened. These options—many of them elegant and convenient— would be the second step once we've capitalized on the benefits of more widespread use of blister packaging. Many seniors already receive e-mail or text reminders on their cell phones from companies like OnTimeRx. That approach and apps like it also provide other ways to help people address their chronic conditions or help loved ones. For instance, they help families serving as caregivers to support the treatment of chronically ill patients. It's very difficult for family members to manage jobs, kids, and other responsibilities while also taking care of an elderly parent. With improved adherence, it's not just patients who get a better quality of life. The fam- ily does, too. As with blister packaging, it's surprising that insurance providers do not recommend or require healthcare providers to use these kinds of adherence-boosting tech- nologies, which are readily available. They seem absent from the discussion, and that's odd. Costs will climb Times are indeed changing, but one fact is certain: The cost of healthcare is increasing every year. Continuing to deliver medication that treats chronic con- ditions using the same old methods won't improve out- comes for patients. Intervention that is both simple and more effective starts with better packaging. It's the best way to reduce what we spend and to increase the quality of life for people with chronic conditions. It's a combina- tion that should appeal to the business people now run- ning the government. Change driven by a business- minded approach—coupled with a genuine concern for patients—should be a slam dunk. Greater adoption would benefit patients, patient cooperatives, insurance compa- nies, and governmental healthcare providers like the VA. What are we waiting for? T&C References 1. The data and figures in this article are taken from "Multiple Chronic Conditions Chartbook–2010 Medical Expenditure Panel Survey Data." Department of Health and Human Services, Agency for Healthcare Research and Quality. The report, published in April 2014, is avail- able at www.ahrq.gov. 2. Lee JK, Grace KA, and Taylor AJ. "Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol: A Randomized Controlled Trial." (FAME study.) JAMA 2006 Dec 6;296(21) 2563-71. Edward J. Bauer is president of Edward J. Bauer and Associ- ates, Sewickley, PA. E-mail: edwardbauer@prodigy.net. He is the author of The Pharmaceutical Packaging Hand- book, and has broad experience in all types of packaging for pharmaceuticals and dietary supplements. He was responsible for worldwide packaging at major pharmaceutical manufac- turers and a medical device manufacturer. He is also an editorial advisor to Tablets & Capsules. His previous article on adherence packaging appeared in the May 2014 issue. 14 May 2017 Tablets & Capsules