MY SUMR

INDIVIDUALIZED INTERVENTIONS TO IMPROVE ADHERENCE IN ASTHMA

Alex RyuMentor: Andrea Apter, MD, MSc

Asthma Brief

Affects 34.1 million Americans, 300M world

Inflammation of airway, comes in “attacks”

217,000 ER visits/yr 2007 national cost: $19.7 billion,

$15B direct Treated with:

Preventative inhaled corticosteroids (ICS’s)

Emergency inhaler – albuterol Prednisone – frequently after ER

Lots of side effects, use briefly

The Context

Racial disparity in asthma morbidity exists

Medications are underused by all populations Even when provided! Asymptomatic nature of asthma

Ability to self-manage key for adherence

Education alone fails Want to design an individualized

intervention to improve adherence Monitoring is necessary, but

problematic

The Issue of Adherence

Poor adherence can be mistaken for poor efficacy of medication

Leads to a cycle of increasing dosages and complexity without improved health

Monitors for common asthma meds do not exist

Patients might incorrectly recall usage habits Drug instructions communicated poorly

Methods of measuring drug container ineffective

Make Your Own Monitor

Need monitors for Advair and Flovent – two main prescribed ICS’s – preventative

Flovent exists, need to design one for Advair

Daniel Bogen, MD, PhD Magnet sensor, basic software

Download at each visit

Advair 100: ~$190/monthAdvair 250: ~$230/monthAdvair 500: ~$315/month

Flovent 110: ~$160/monthFlovent 220:~$180/month

Diskus Adherence Logger (DAL)

Bogen, Apter JACI 2004;114:863.

Early Investigation

Focus groups – Influences on adherence Latino and African American patients Identified barriers to adherence

Piloted Problem Solving intervention (PS) Ancillary staff at outpatient visit Designed to help reduce barriers to

adherence

Study Design

RCT, participants receive either Attention Control (AC) or Problem-Solving (PS) intervention Same length, education previously found

ineffective Meet 8 times, around participants’ schedules

Do spirometry, ask questions, do intervention, download adherence data

Cost-free Questions regarding other relevant issues

Where get meds, reading ability, depression, etc…

Independent Variables(A few)

Self-Efficacy

Social Support

Depression

Cost of medication

Knowledge of asthma and medication use

Dependent Variables

Adherence

Asthma-Related Quality of Life (QOL)

Asthmatic Control

Specific Aims

Determine whether PS improves adherence over AC

Test whether PS improves pulmonary function over AC

Determine whether PS improves asthma-related QOL over AC

Exploratory Aims

Examine whether patients’ knowledge of and attitude toward ICS mediate PS, adherence

Examine whether social and environmental interactions mediate PS, adherence

Estimate financial impact of intervention

Hypothesis

PS will improve adherence over AC

PS will improve FEV1 over AC

PS will improve asthma-related QOL more than AC

Recruitment

Recruit from UPHS clinics + Episcopal Hospital + VA + Woodland Av – mostly minority

Chart searches

Contact over phone or in person

Screen

Enroll

Eligibility Criteria

≥ 18 years of age Currently prescribed a either Advair

or Flovent Pre-bronchodilator FEV1 <80% Post-bronchodilator FEV1 increase by

12% No pulmonary htn, or other disease

that impairs asthma-related lung measurements

No cognitive or mental impairments

What I did…

Recruitment Charts – Epic, Mediview Screening appointments

Compiled participant copay receipts

Administrative tasks Monitors Clinical research ≈ PAPER

Status

Finally enrolled 400th participant – unparalleled sample size for this type of study 5 years in the making

Continuing to follow with visits Some preliminary analyses, most

data still frozen until study complete Have baseline adherence,

questionnaires Database of copay receipts for later

analysis Dan Polsky PhD, MPP, Sean McElligott

Limitations

Much of secondary data is self-reported

Potential effects of “attention-factor”

Differing reimbursement patterns

Difficulty with scheduling and retention

Lots of Time + Lots of Money=…

Better characterization of impoverished minority patients with moderate/severe asthma

A better understanding of treatment plans to improve ICS adherence

Insights into the numerous social and societal barriers that deter adherence

* Ideally, a set of treatment guidelines that will shrink the national financial burden of asthma through improved adherence

Lessons

Recruitment takes patience

Good health is more than not having a cough

Appreciation for complex logistics

A HUGE Thanks to:

Dr. Andrea Apter Laura Garcia, MPH Rodalyn Gonzalez and Chantel Priolo Participants Joanne Levy, MBA MCP Shanta Layton LDI and SUMR HUP