kristin a. riekert, phd associate professor co-director, johns hopkins adherence research center...
TRANSCRIPT
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Kristin A. Riekert, PhDAssociate ProfessorCo-Director, Johns Hopkins Adherence Research Center
ADHERENCE…
WHERE’S THE APP FOR THAT?
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GileadConsulting, medical affairs advisory program
NovartisConsulting
Cystic Fibrosis FoundationInstitutional contract to conduct the iCARE adherence
study
NIHInstitutional contract to conduct the BALANCE adherence
study
DISCLOSURES
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A VISION FOR THE FUTURE
Is our job done?
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THE EXPERTS
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DEBUNKING MYTHS &
SCOPE OF THE PROBLEM
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NACFC 2012 Poster #464
ADHERENCE BY DRUG
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NACFC 2012 Poster #464
ADHERENCE BY AGE
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# PRESCRIBED PULMONARY MEDICINES
Each individual drug’s MPR increases with the # prescribed pulmonary medicationsNACFC 2012 Poster #464
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IMPACT OF NONADHERENCE
Eakin et al. JCF 2011, 258-264
Lung Function
020
4060
80100
Com
pos
ite M
PR
0 1-2 3+
Courses of IVs
Courses of IVs
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Controlling for: gender, age, comorbidities, index year, number of unique pulmonary medications dispensed and average monthly drug copay at baseline.
ALL-CAUSE INPATIENT COSTS
NACFC 2012 Symposium #18
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WHY IS ADHERENCE SO CHALLENGING?
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HOW COMPLICATED CAN IT BE?
Individual
• Age• Gender • Health Literacy• Disease & Treatment Knowledge• Mental Health/Behavioral Problems• Coping Style• Health Beliefs & Perceptions
Health Care System• Access to Care• Continuity of Care• Patient-Provider Communication• Shared Decision Making• Frequency of Clinic Visits• Provider Biases
Family
• Family Structure• Income/Health Insurance • Disease Knowledge• Mental Health/Behavioral Problems• Coping Style• Health Beliefs & Perceptions• Relationship quality• Involvement in care
Adapted from Modi et al., Pediatrics 2012, e473-85
Community • Neighborhood • Work (Hours & Policies)• School• Peer Support• Illness Stigma
ADHERENCE
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KNOWLEDGE
020
4060
8010
0K
no
wle
dg
e S
core
s
NON-ADHERENT ADHERENT
p=.17
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WeightCF-Nutrition Knowledge
EDUCATION ISN’T ENOUGH
Education Control
Watson et al. J Am Diet Assoc 2008: 847-52 * p< .05
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• The TIDES Study (N=1159)
• Adolescents (12-<18) = 22%
• Young adults (18-<35) = 13%
• Older adults (35-73) = 21%
DEPRESSION PREVALENCE
Unpublished data courtesy of Alexandra Quittner, PhD & Michael Schechter, MD (TIDES PIs)
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DEPRESSION
NON-ADHERENT
ADHERENT
Pro
port
ion
Scr
eeni
ng P
ositi
ve
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MOTIVATION
On a scale of 1 to 10, how
motivated are you to take your medicine every
day?
KEY TREATMENT BELIEFS
On a scale of 1 to 10, how
important do you think it is to take your medicine
every day?
IMPORTANCE
p=.06
12
34
56
78
910
NON-ADHERENT ADHERENT
p=.03
12
34
56
78
910
NON-ADHERENT ADHERENT
On a scale of 1 to 10, how
confident are you that you can take
your medicine when…?
SELF-EFFICACY
p<.01
12
34
56
78
910
NON-ADHERENT ADHERENT
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WHAT CAN WE DO TO SUPPORT
ADHERENCE?
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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
“MULTI-COMPONENT” INTERVENTIONS ARE BEST
Haynes et al. Cochrane Database of Systemic Reviews 2008 Kahana et al. J Pediatr Psychol. 2008:590-611
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Caloric Intake Weight
EDUCATION + BEHAVIORAL
Behavioral + Education Education
***
* p< .01; ** p<.001 Stark et al. Arch Pediatr Adolesc Med 2009: 915-21
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ONGOING TRIALS
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WHAT ARE OUR NEXT STEPS?
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TWO PLACES TO START
Accurately identify who is nonadherent
Explore ways to make interventions more practical for patients, families and care teams
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THE CHALLENGE
0
PATIENT REPORT PROVIDER REPORT
Daniels et al. Chest 2011; 425-32
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OBJECTIVE MONITORING OPPORTUNITIES
www.gentag.com
www.healthcare.philips.com
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LEVERAGING TECHNOLOGY
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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, 2011Adult data: The Pew Research Center’s Internet & American Life Project, April 26-May 22, 2011
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As of April 2012 there were over 13,600 health apps for the Apple iPhone – <2% target medication adherence.
-mobihealthnews
July 2012
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WHY CONSIDER HEALTH APPS?
Appealing to our patients
Convenient for patients
Cheaper
Disseminable
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CF-NOTEBOOK APP
Screen Shots Courtesy of Michael Marciel
• Diary function to log activities
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Not on the market yet
MANGO HEALTH
• Log activities
• Reminders
• Compare to others on same drug
• Incentives—points, discounts & rewards
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SPIROSMART MONITOR
Ubiquitous Computing (UbiComp) Research lab led by Shwetak Patel, University of Washington
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PERSONALIZED FEEDBACK
Unpublished data courtesy of Dr. Noah Lechtzin, Johns Hopkins School of Medicine
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OPPORTUNITIES
Capitalize on real-time data collection & feedback
GamificationRewardsStatusCompetitionAltruism
Social Networking
Dynamic & changing Nike Training Club app
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DO assess adherence at each visitPharmacy recordsPatient 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 adherenceWhat makes it challenging to follow your treatment plan?
DO problem-solve with the patientDO partner with mental health professionals
IN THE MEANTIME…
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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
SUMMARY
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A VISION FOR THE FUTURE
Is our job done?
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OUR JOB IS JUST BEGINNING
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My Mentors:Dennis Drotar, PhDCynthia Rand, PhDAlexandra Quittner, PhD
JHARC Faculty & StaffMichelle Eakin, PhDMarisa Hilliard, PhDAlana RidgeAndrew Bilderback, MSAngela GreenSuzanne LawsonDevin Rand-GiovanettiAnthony StanfieldMany more…
The CF ExpertsChaseKatherineMeganMelissa
The Johns Hopkins Pediatric & Adult CF Care Teams
My Awesome FamilyKeithAndyCooper
ACKNOWLEDGEMENTS