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Adherence… where’s the app for that?

Adherence… where’s the app for that?. Kristin A. Riekert, PhD Associate Professor Co-Director, Johns Hopkins Adherence Research Center. Disclosures. Gilead C onsulting , medical affairs advisory program Novartis C onsulting Cystic Fibrosis Foundation

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Adherence… where’s the app for that?

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  1. Adherence… where’s the app for that? Kristin A. Riekert, PhD Associate Professor Co-Director, Johns Hopkins Adherence Research Center

  2. Disclosures • Gilead • Consulting, medical affairs advisory program • Novartis • Consulting • Cystic Fibrosis Foundation • Institutional contract to conduct the iCARE adherence study • NIH • Institutional contract to conduct the BALANCE adherence study

  3. A Vision for the Future Is our job done?

  4. The experts

  5. Debunking myths & Scope of the Problem

  6. ADHERENCE BY DRUG NACFC 2012 Poster #464

  7. ADHERENCE BY AGE NACFC 2012 Poster #464

  8. # Prescribed Pulmonary Medicines Each individual drug’s MPR increases with the # prescribed pulmonary medications NACFC 2012 Poster #464

  9. 100 80 60 Composite MPR 40 20 0 0 1-2 3+ Impact of Nonadherence Courses of IVs Lung Function Courses of IVs Eakin et al. JCF 2011, 258-264

  10. ALL-CAUSE INPATIENT COSTS Controlling for: gender, age, comorbidities, index year, number of unique pulmonary medications dispensed and average monthly drug copay at baseline. NACFC 2012 Symposium #18

  11. Why is adherence so challenging?

  12. how complicated can it be? Individual Health Care System Family Community • Access to Care • Continuity of Care • Patient-Provider Communication • Shared Decision Making • Frequency of Clinic Visits • Provider Biases • Neighborhood • Work (Hours & Policies) • School • Peer Support • Illness Stigma • Age • Gender • Health Literacy • Disease & Treatment Knowledge • Mental Health/Behavioral Problems • Coping Style • Health Beliefs & Perceptions • Family Structure • Income/Health Insurance • Disease Knowledge • Mental Health/Behavioral Problems • Coping Style • Health Beliefs & Perceptions • Relationship quality • Involvement in care ADHERENCE Adapted from Modi et al., Pediatrics 2012, e473-85

  13. 100 80 60 Knowledge Scores 40 20 0 NON-ADHERENT ADHERENT Knowledge p=.17

  14. Education isn’t enough  Education Control Weight CF-Nutrition Knowledge * p< .05 Watson et al. J Am Diet Assoc 2008: 847-52

  15. Depression Prevalence Unpublished data courtesy of Alexandra Quittner, PhD & Michael Schechter, MD (TIDES PIs) • The TIDES Study (N=1159) • Adolescents (12-<18) = 22% • Young adults (18-<35) = 13% • Older adults (35-73) = 21%

  16. Depression Proportion Screening Positive NON-ADHERENT ADHERENT

  17. p=.03 p=.06 p<.01 10 10 10 9 9 9 8 8 8 7 7 7 6 6 6 5 5 5 4 4 4 3 3 3 2 2 2 1 1 1 NON-ADHERENT ADHERENT ADHERENT NON-ADHERENT ADHERENT NON-ADHERENT kEy treatment Beliefs Importance Motivation Self-Efficacy On a scale of 1 to 10, how important do you think it is to take your medicine every day? On a scale of 1 to 10, how motivated are you to take your medicine every day? On a scale of 1 to 10, how confident are you that you can take your medicine when…?

  18. What can we do to support Adherence?

  19. “multi-Component” Interventions are best • Education • Reminders/Cueing • Self-Monitoring • Tailoring the Regimen • Health & Behavioral Feedback • Problem-Solving • Contingencies & Rewards • Directly Observed Therapy • Social Support • Parent-Training • Family Therapy • Cognitive Behavioral Therapy • Motivational Interviewing Haynes et al. Cochrane Database of Systemic Reviews 2008 Kahana et al. J Pediatr Psychol. 2008:590-611

  20. Education + Behavioral  Behavioral + Education  Education Caloric Intake Weight ** * * p< .01; ** p<.001 Stark et al. Arch Pediatr Adolesc Med 2009: 915-21

  21. Ongoing trials • BALANCE (PI: Riekert) • Motivational Interviewing vs. Problem-Solving • iCARE (PIs: Quittner & Riekert) • CF My Way vs. Standard Care • CFFone(PI: Quittner) • Social Networking vs. Standard Care • Be-In-CHARGE!(PI: Stark) • Translation of FTF intervention to web-based

  22. What are our next Steps?

  23. Two places to start Accurately identify who is nonadherent Explore ways to make interventions more practical for patients, families and care teams

  24. The challenge Patient Report Provider Report 0 Daniels et al. Chest 2011; 425-32

  25. Objective Monitoring Opportunities www.healthcare.philips.com www.gentag.com

  26. Leveraging technology

  27. Who Doesn’t have a cell phone? Teen data: The Pew Research Center’s Internet & American Life Project, Teen/Parent Survey April 19-July 14, 2011 Adult data: The Pew Research Center’s Internet & American Life Project, April 26-May 22, 2011

  28. As of April 2012 there were over 13,600 health apps for the Apple iPhone – <2% target medication adherence. -mobihealthnews July 2012

  29. Why consider health apps? Appealing to our patients Convenient for patients Cheaper Disseminable

  30. CF-Notebook app • Diary function to log activities Screen Shots Courtesy of Michael Marciel

  31. Mango Health • Log activities • Reminders • Compare to others on same drug • Incentives—points, discounts & rewards Not on the market yet

  32. SpiroSmart monitor Ubiquitous Computing (UbiComp) Research lab led by Shwetak Patel, University of Washington

  33. Personalized Feedback Unpublished data courtesy of Dr. Noah Lechtzin, Johns Hopkins School of Medicine

  34. Opportunities Nike Training Club app • Capitalize on real-time data collection & feedback • Gamification • Rewards • Status • Competition • Altruism • Social Networking • Dynamic & changing

  35. In the meantime… • DO assess adherence at each visit • Pharmacy records • Patient report • Which, if any meds, have you been taking?... How are you taking [name med]?... • DON’T respond with a lecture! • Remember education is necessary but not sufficient • DO assess barriers to adherence • What makes it challenging to follow your treatment plan? • DO problem-solve with the patient • DO partner with mental health professionals

  36. Summary Nonadherence is a significant clinical problem Why someone is nonadherent is complex and personal Need many tools in our tool box to support our patients and families Emerging technology may be useful

  37. A Vision for the Future Is our job done?

  38. Our job is just beginning

  39. Acknowledgements • The CF Experts • Chase • Katherine • Megan • Melissa • The Johns Hopkins Pediatric & Adult CF Care Teams • My Awesome Family • Keith • Andy • Cooper • My Mentors: • Dennis Drotar, PhD • Cynthia Rand, PhD • Alexandra Quittner, PhD • JHARC Faculty & Staff • Michelle Eakin, PhD • Marisa Hilliard, PhD • Alana Ridge • Andrew Bilderback, MS • Angela Green • Suzanne Lawson • Devin Rand-Giovanetti • Anthony Stanfield • Many more…

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