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Adherence Tools of Yesterday, Today and Tomorrow

Explore adherence terminologies, risk factors, traditional and modern tools, and technologies to monitor medication adherence for improved patient outcomes.

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Adherence Tools of Yesterday, Today and Tomorrow

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  1. Adherence Tools of Yesterday, Today and Tomorrow Seth Heldenbrand, Pharm.D. Associate Professor University of Arkansas for Medical Sciences

  2. Disclosure • Financial disclosures • I have no financial conflicts to disclose

  3. Objectives • Summarize adherence terminology/epidemiology • Identify risk factors for non-adherence and tools to measure it • Evaluate traditional methods used to improve/monitor medication adherence • Review today’s technologies for improving/monitoring medication adherence • Summarize tomorrow’s technologies for improving/monitoring medication adherence

  4. Definition of Adherence • Compliance • “the extent to which a patient’s behavior matches the prescriber’s recommendation” • Adherence • “the extent to which the patient’s behavior matches the agreed upon prescriber’s recommendation” Fine RN, et al. Nonadherence Consensus Conference Summary Report; American Journal of Transplantation 2009; 9: 35–41

  5. So What Is Nonadherence (NA)? • “Deviation from the prescribed medication regimen sufficient to influence adversely the regimen’s intended effect”. Fine RN, et al. Nonadherence Consensus Conference Summary Report; American Journal of Transplantation 2009; 9: 35–41

  6. NA In the U.S. • Adversely affects health • Negative impact on relationship with health care provider • Skew results of clinical trials • Increases health resource consumption

  7. Epidemiology of NA • General population • 33-69% of medication related hospitalizations • $100 billion annually • Adherence to chronic medications is approximately 50% Dayer, L., Heldenbrand, S., Anderson, P., Gubbins, P. O., & Martin, B. C. (2013). Smartphone medication adherence apps: potential benefits to patients and providers. Journal of the American Pharmacists Association, 53(2), 172-181.

  8. Measurement of Adherence • Direct • Observation of ingestion • Physical or electronic • Indirect • Patient self-reports • Pill counts • Refill rates • Blood monitoring • Electronic monitoring What are the drawbacks to these indirect methods?

  9. Types of NA • Intentional • Rational decision • Beliefs/feelings • Unintentional • Intending to take the medication • Forgetfulness • Carelessness • Financial

  10. Risk Factors for NA • History of NA • Psychiatric illness • Personality disorders • Substance abuse • Adolescence • Chronic illness • Physician communication • Illiteracy • Low self efficacy • Side effects • Cost • Complex regimen • Poor aftercare/discharge • Negative beliefs in medications • Socioeconomic status • History of abuse • Race/culture Fine RN, et al. Nonadherence Consensus Conference Summary Report; American Journal of Transplantation 2009; 9: 35–41

  11. Methods to Improve Adherence • Behavioral • Reminder systems • Educational • Counseling reinforcement • Organizational • Decreasing regimen complexity • Removing barriers • $$$

  12. Medication Adherence Aids • Traditional • Best for unintentional NA • Pill boxes, unit-of-use packaging, alarms • Minimally involves patient in the process • Provide no adherence data • Many are passive systems

  13. Behavioral Interventions • Patient education • Best method to improve adherence • Especially for those taking more than six medications • Emotional intelligence • Motivational interviewing

  14. New and Emerging Adherence Technologies • Mobile Adherence Applications “Apps” • Internet-connected adherence monitoring technologies • Electronic and biometric ingestion confirming technologies

  15. Improving Adherence In Your Patients • NA is multifactorial • Interventions should be customized for each patient and pattern of NA • Foundation should be educational and behavior modifying • Multiple approaches should be used simultaneously

  16. Traditional Adherence Tools

  17. Traditional Adherence Tools • Counseling/Education • Regimen books “black books” • Regimen print outs • Administration check lists • Pill boxes (and other pill reminder tools)

  18. Counseling/Education • Time intensive • Health literacy concerns • Communication skills (YOURS and theirs) • Knowledge of health topics (YOURS and theirs) • Culture • Barriers to health system/care • Demands of situation/context • Education in non-health areas (reading, math, general education level)

  19. Clear Communication • Warm greeting • Eye contact • Plain, non-medical language • Slow down • Limit content (3-5 points) • Repeat key points • Graphics (when applicable) • Patient participation • Teach-back

  20. Teach-back Method • What percentage of medical information if forgotten immediately • 40-80% • What percentage of information retained is incorrect? • Almost 50% • Teach-back involves asking the patient to repeat what you have just told them • Repeat the process until they get it right • Confirms patient understanding of instructions

  21. Teach-back Method • Not a test of the patient knowledge • It is a test of how well you explained the concept • Use with everyone • Even when you think they understood • Should be used by all medical staff • MD/RN/PharmD/everyone

  22. Follow-up with Patients • Monitoring health (BP, blood sugar, weight) • Reinforcing action plans • Assessing/Confirming adherence • Verifying follow-through on referrals • Communicating lab results

  23. “Black Books” • Contact info • Brand/Generic • Each med is a card • Pencil • Patient’s responsibility

  24. Medication Regimenswww.medactionplan.com • Brand and generic names • Pictures of the meds • Drug, strength, dose, time • Contact information www.medactionplan.com

  25. Administration Checklists • Continues inpatient administration procedure as an outpatient • Not for every patient • “Type A” comes to mind… www.medactionplan.com

  26. Traditional Reminders • Daily pillbox ($2.49) • Weekly pillboxes ($11.24) • Electronic pillboxes ($13.99) • Wearable digital reminder alarms ($139.95)

  27. Other Adherence Tools • Multi-Alarm Pocket ($39.95) • Multi-Alarm TimeCap ($29.95) • MEDglider 4 Alarm Pillbox ($45.95) • CompuMed Automated Dispenser ($895)

  28. Other Adherence Tools • MEMS 6 TrackCap($107 for TrackCap; $365 for reader) • SenticarePillStation($89 enrollment; $79 per month) • GlowCaps(discussed later)

  29. Mobile Adherence Technologies “Apps”

  30. J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  31. Adherence Apps • Using a smartphone to improve adherence is still a novel approach • Consolidates health information onto one ubiquitous device • Little to no cost to the patient • Simplifies complex regimens • Literature on health and wellness is growing • Adherence data is lacking (although some promising results) J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  32. 2012 App StudyValuable App Attributes • Online data entry • Complex instruction capable • Cloud data storage • Searchable database of medications • Sync/export/print data • Tracks missed and taken doses • Provider data input capable • Multi-platform app • HIPAA compliant • Multiple profile feature • Multilingual J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  33. 2012 App Study Methods • Inclusion • iPhone, Android, Blackberry OSs • English language • Must generate reminders • Exclusion • Designed for one medication type • Designed single disease state • Lacked description of functionality J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  34. 2012 App Study Results • 160 apps reviewed (147 unique) • Scored and ranked based on author point system • Ten highest ranked apps were tested on available operating systems • Apps were evaluated against developer claims J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  35. J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  36. 2012 Rank Post-testing • MyMedSchedule • MyMeds • MedSimple • Med Agenda (iOS only) • RxmindMe (iOS only) • Dosecast • TRxC (Beta) • MediMemory (iOS only) • PillManager • MedsIQ Individual/Multi-User (Android only) J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  37. 2014 App Study (Preliminary) • Similar Inclusion and Exclusion criteria • Modified “important features” • Tested the top 100 scoring apps

  38. 2014 App Study (Preliminary) • 461 apps reviewed (329 unique) • Scored and ranked based on author point system • 100 highest ranked apps were tested on available operating systems • Apps were evaluated for real world performance against developer claims

  39. Total Apps 2012 - 2014

  40. Apps by OS 2012 - 2014

  41. 2014 App Study (Preliminary) • What did we learn? • The adherence app market place is exploding • It is difficult for patients to choose quality apps • Most “free” apps are not worth the effort • Limited functionality (bait apps) • Poorly finished • Packed with adds • False claims by developers

  42. Selecting the right app • Developing an adherence app website • Lets patient or provider select desired functions • Ranks apps by our features/testing formula by desired features • Eliminates the trial and error approach to medication adherence apps that exists now

  43. Future Directions for Apps • Growing smartphone use (55% in US) • 14-42% persons age 65 or older • Companion websites for patients and providers • Escalating reminder systems • Tailored reminder systems • Motivating reminders • Less intrusive reminders for the adherent patient J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  44. Future Directions for Apps • Connectivity: Real-time adherence info • Interconnectivity: synced hospital info, discharge instructions, pharmacy records • Medical social networks: patient specified providers apps contact at NA thresholds • Integration with ingestion sensor systems: the “holy grail” of adherence measurement J Am Pharm Assoc. 2013;53:172–181. doi: 10.1331/JAPhA.2013.12202

  45. Emerging and Available Adherence Technologies

  46. GlowCapswww.glowcaps.com • Cellular (AT&T) • Caps communicate with base to track adherence • Progressive reminders • Light up (cap) • Light up (base) • Play ringtone • Call/text patient • Requests Rx refills • Weekly adherence report

  47. GlowCaps • Cost • $10 per cap • $15 per month AT&T • Results • Single study • Improved adherence from 71% to 98% • Other studies pending or unpublished • Current trials underway in transplant recipients

  48. 6 month study randomized (nearing completion and publication hopefully) • Once a day meds for HTN • 27% increase in adherence over the control group (early results) • Funded by GlowCaps

  49. Similar Electronic Cap Technologies • eCAP • Beeps and flashes • RFID communication • MEMS 6 TrackCap • Records • bottle openings • uploads via reader

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