Improving Chronic Inhaler Adherence

in Adolescent Populations

By: Nicholas Gast, Heather Goodwin, Catherine Smith, Kimhouy Tong, Mitchell Tucci

Before we begin…. -SMS (Short Message Service)

-Chronic vs. Acute Asthma

-Maintenance vs. Rescue inhalers

Presentation Goals-Demonstrate the need for an intervention program for adolescents with chronic asthma-Describe the innovation and logic behind our texting program-Develop the implementation, cost, data collection and analysis and overall expectations of the proposed program-Examine future directions and gain your valuable insights!Please hold all questions until the end of the presentation

Adolescent asthma -Asthma is a leading chronic illness among children and adolescents

-Rates of Asthma in children and adolescents are increasing worldwide (Woolcock et al., 1997)

-21% of U.S. high school youths were at one time diagnosed with asthma (CDC YRBS, 2013)

-Medication adherence rates decline throughout adolescence:-Forgetfulness to take maintenance inhaler seen as major

reason for nonadherence -Parents were perceived as the main reminding force-Lack of perceived need or beneficial effects (Koster et al.,

2015)

-Previous research has examined web-based interventions for chronic medication adherence (Base et al., 2015)

-Very preliminary and qualitative

Teens and medication adherence

ObjectiveImplement an SMS-based program for a community pharmacy setting that directly reminds adolescents to 1) take prescribed medication for chronic asthma and 2) respond post-administration Aims: -Decrease forgetfulness -Increase involvement in self-management-Improve adherence and thus quality of life

Significance and Innovation

-Target population is notoriously nonadherent (Koster et al., 2015)

-First study examining the efficacy of two way texting on chronic medication adherence in an adolescent population

-New approach to increase perceived control of asthma

Pilot Design: Site Selection

- Site: Community pharmacy - Major source of primary care- Easily accessible for patients- Find sites with high customer

loyalty - Patients will purchase

medications only from this site- Ensures comprehensive

pharmacy profiles for data analysis

Pilot Design: Recruitment- Recruitment: adolescents with chronic asthma ages

13 - 17 - Rationale: 78% American children ages 12-17

own cell phones (Madden et al., 2013)- Adolescents picking up steroidal inhalers will be

invited to join pilot- Retention: those who complete study will be eligible

for raffled prizes- itunes/google play gift cards, ipad

Pilot Design: Cost Analysis

- The majority of teenagers have cell phones already

- Participation will only be available to those with a mobile device

- In a study using SMS to improve diabetic medication use average cost per SMS was 70 cents (Haddad et al., 2014)

- Possible vendor solutions...

Sample Texting Vendor

Pilot Design: Payer IncentiveWhere is the incentive for profit?- Community pharmacy:

increased adherence → increased dispensing

- Insurance company: steroidal inhalers directly help limit asthma exacerbations that lead to emergency room visits--Higher emergency department visit rates in children and adolescents compared to adults (Akinbami et al., 2012)

Data Collection and Analysis

-Patients will respond to SMS prompt and information will be relayed back to the pharmacy

-responses will be catalogued and utilized to determine the patient’s adherence-actual adherence will have no effect on whether the patient is eligible for prizes

Data Collection and Analysis

-If patient responds an automatic reply will be generated informing them they are entered to win a prize

-Each response earns additional entries to win-Pre-existing inhaler dose-counters will be utilized to measure adherence, in addition to text responses

-Parents will be encouraged to bring old inhalers to the pharmacy during refill for analysis-Returned inhalers will be incentivized with coupons for savings

Data Collection and AnalysisAt the conclusion of the test period, an anonymous

survey will be distributed to collect further information

-Anonymous aspect may allow for more truthful answers

-The pharmacy can utilize the survey to discover the patient’s attitude toward the program and what are the patient’s perceived roadblocks to adherence

All collected data will then be statistically analyzed to determine if the program is successful in increasing adherence among the participants

Expectations-Increase medication adherence in adolescents using steroidal inhalers chronically-Increase the the quality of life of patients by increasing their ability to participate in activities with peers-Provide benefits to insurance companies by reducing cost (Altman, 2011)

Why are the Results Expected?

-Approximately 78% of adolescents ages 12-17 have a cell phone (Madden et al., 2013)-63% say they exchange text messages every day, surpassing the frequency of all other communication forms (Lenhart, 2012)-Adolescents are already comfortable with cell phone monitoring and identify SMS messaging as their preferred method of contact

Potential Limitations-Truthfulness of adolescents

-Lack of involvement of parents

-Lack of involvement by pharmacists

-Could be identified by administering an anonymous survey

Example Survey

Alternative Approaches-The parent(s)/guardian could also receive a two-way SMS message -Send automatic alerts to the pharmacists notifying them of missed doses once the adolescent has not responded-To overcome the potential limitation of the time of day that the SMS is sent, a reminder message could be sent at a later time during the day

Future Directions1. Broaden the scope of clinical indications served

to include other chronic medication schedules-E.g. Insulin in Type I Diabetes (“Juvenile

Diabetes”)2. Increase the accessibility of the 2 Way SMS System

-Low literacy: text picture of medicine as a reminder

-Translate texts into commonly spoken languages (e.g. Spanish)

Future Directions 3. Develop multi-media platform to include health network and social network

-Reinforces adherent behavior with peer support

Summary- 2 Way SMS: Text reminders that prompt users to send a response text after taking their medications

-This pilot could serve as a template for other medication regimens that are temporally sensitive

-This strategy can potentially improve chronic medication adherence in tech savvy populations such as adolescents

Timeline

Site Selection & Training

Patient Enrollment

2-Way SMS Data Collection

QOL Survey

Data Analysis

Month 3 6 9 12 15 18 24

Questions?Some things to consider…

-What other patient groups could benefit from 2 Way SMS?

-How could we incorporate social media into the program?

ReferencesWashington State.(2013). “How Asthma Affects the Qaulity of Life in Youth Avaliable at http://www.doh.wa.gov/Portals/1/Documents/Pubs/345-332-QualityOfLife.pdf. Accessed on July, 21,2015. Lv, Yanhua,Zhao, H., et al. (2014). A Mobile Phone Short Message Service Improves Perceived Control of Asthma: A Randomized Controlled Trial. Telemedicine and e-Health, 18, 420-426 doi: 10.1089/tmj.2011.0218 Greenwood, V. Why are asthma rates soaring?. In: Scientific American. April 2011. Accessed July 31, 2015. http://www.scientificamerican.com/article/why-are-asthma-rates-soaring/?page=3

Bass, A. M., Farhangian, M. E., & Feldman, S. R. (2015). Internet-based adherence interventions for treatment of chronic disorders in adolescents.Adolescent Health, Medicine and Therapeutics, 6, 91–99. doi:10.2147/AHMT.S56065

American Lung Association, Epidemiology and Statistics Unit, Research and Program Services. Trends in Asthma Morbidity and Mortality. January 2009.

Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. NCHS data brief, no 94. Hyattsville, MD: National Center for Health Statistics. 2012.

Haddad Nazar S., Istepanian Robert, Philip Nada, Khazaal Faris A.K., Hamdan Thamer A., Pickles Timothy, Amso Nazar, and Gregory John W.. Diabetes Technology & Therapeutics. July 2014, 16(7): 454-459.

Centers for Disease Control and Prevention. 2013 Youth Risk Behavior Survey. Available at: www.cdc.gov/yrbs. Accessed on July 31, 2015.Weisskirch, R.F. Parenting by Cell Phone: Parental Monitoring of Adolescents and Family Relations. Journal of Youth Adolescence. (2009) 38:1123–1139. DOI 10.1007/s10964-008-9374-8Woolcock AJ, Peat JK. Evidence for the increase in asthma worldwide. In: The Rising Trends in Asthma. West Sussex:John Wiley & Sons Ltd; 1997 p. 122-139.