powerpoint presentation · –clinical practice improvement activities 15% ... asthma outcomes when...

10/24/2016

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An Asthma Telehealth Program to Improve Adherence to Inhaled

Corticosteroid Therapy

11th Annual Nemacolin Asthma Conference

October 29, 2016

Andrew G Weinstein MD President, Asthma Management Systems

Disclosures

• National Institute Health

• Merck

• President Asthma Management Systems

Overview of Presentation

• The Importance of Adherence and Outcomes

• Asthma Adherence Management Model

• Application of Model: Case Example Steroid Phobia

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Asthma Treatment Mantra

Correct Diagnosis

Correct Treatment

Adherence to Treatment

Morbidity, Cost

QOL

Medical Reimbursement

ADHERENCE OUTCOMES

• Fee for service - - Prior to 2017

• Value / At Risk + + 2017 on

Merit-based Incentive Payment System

Four categories of clinician performance derive

Composite Performance Score (CPS)

– Quality 50%

– Advancing Care Information (formerly Meaningful Use) 25%

– Clinical Practice Improvement Activities 15%

– Resource Use 10%

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Merit-Based Incentive Payment System

Source: http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips

MIPS Scoring Asthma Includes

• Cost of care $

• Practice pattern/instruments used to control disease ACT

• Quality of care provided Asthma Impact Scale AIS

• Adherence/Compliance %

• Clinical Practice

Population Management

Care Coordination Tele-health

Self-management Training

Adherence Management Model

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Mean Daily Adherence With ICS

Intervention: Patient Feedback

– Standard asthma care

– Monitoring by MDI chronologs

– Direct clinician-to-patient

feedback for treatment group

19 subjects RCT; single blind

Onyirimba et al. Ann Allergy Asthma Immunol. 2003;90:411-415.

1 2 3 4 5 6 7 8 9 10

20

30

40

50

60

70

80

90

Treatment

Control

Me

an

Da

ily

Ad

he

ren

ce

Week of Study

ASTHMA ADHERENCE MANAGEMENT PROVEN OUTCOMES

• Diagnose Adherence Status

• Identify Barriers

• Select Appropriate Strategy

• Optimize Communication Skills

Weinstein JACI:InPractice 2013

Asthma Adherence Disease Management

• 3 Uncontrolled trials 70% reduction in cost

– Nemours inpatient/outpatient child asthma rehab

– BCBSDE Monitoring program

2 Ongoing controlled trials :

NIH at Geisinger Health Plan: Nurse case manager

• Merck: Highmark Pittsburgh: Allergists/Pulmonologists

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Dulera Adherence Ongoing Study

• 40 persistent adult asthma 20 control/ 20 intervention

• Asthma Control Questionaire > 1.0

• 15 completed Intervention Asthma Adherence Pathway

– Identify barriers to adherence

– Clinical Decision Intervention/Motivational Interviewing

– Monitored Dulera Adherence at time of visit

• Mean Adherence Intervention group

• ACQ Initial 3 month Follow up

Control

Intervention

Solution: Asthma Adherence Pathway web-app(AAP™)

PATIENT PORTAL PROVIDER PORTAL

Patient login

Step 2: Patients self-identify barriers to Rx with validated survey

Provider login

Step 3: Clinicians identify hi-risk patients and respond with clinical decision support strategies

Survey data

• Extensive library of digital and video educational resources addresses barriers to adherence identified in survey

• Adherence strategies supported with robust guidelines and literature links

Provides analysis and objective monitoring: why patients don’t adhere to Rx

Step 1: Real time objective adherence monitoring (preventative/rescue)

Step 4: In-person and remote communications training: Shared- Decision-Making and Motivational interviewing

Asthma Outcomes When Theophylline Monitoring Severe Asthmatic Children After Intensive Rehabilitation

1 Year

Prior Median

(5-95 Pctl.)

n=59

1 Year Post

Median

(5-95 Pctl.)

n=59

2nd Year

Post Median

(5-95 Pctl.)

n=59

3rd Year

Post Median

(5-95 Pctl.)

n=57

4th Year

Post Median

(5-95 Pctl.)

n=51

Total Cost

(dollars)

$10,240

(1,874-27,964)

$4,036

(1,696-13,450)

$2,801

(940-8,625)

$2,316

(450-8,425)

$1,936

(340-7,311)

Inpatient Days 7 (0-25) 0 (0-6)* 0 (0-4)*

0 (0-4)*

0 (0-4)*

Emergency

Care

4 (1-11)*

0 (0-5)*

0 (0-5)**

0 (0-2)*

0 (0-2)*

Corticosteroid

Bursts

2 (0-9)

2 (0-8) 1 (0-5)* 1 (0-4)*

1 (0-5)*

Physician

Visits

2 (3-24) 2 (0-11) 1.5 (0-8) 2 (0-8) 2 (0-8)

*P<0.001 **P<0.01

Weinstein et al. JACI. 1996;98:264-273.

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Weinstein JACI:IP 2013

Assessing Adherence Status

Methods

– Question the patient

– Evaluate patient diaries for completeness

– Ask patient to complete questionnaire

– Assess adherence based on response to treatment

– Conduct pill counts

– Use electronic monitors

– Determine prescriptions filled at pharmacy

– Blood/Urine

– Observation

Adherence with Asthma Therapy by Diary and Electronic Monitoring

Milgrom H, Bender, B, Rand, C., J Allergy Clin Immunol, 1996:1051-57

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Nonadherence is associated with increased

risk of disease exacerbations

Milgrom H, Bender, B, Rand, C., J Allergy Clin Immunol, 1996:1051-57







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Factors (Barriers) Involved in Non-Adherence GINA 2008

Drug Factors

• Difficulties with inhaler devices

• Awkward regimes

(e.g.,four times daily or multiple drugs)

• Side effects

• Cost of medication

• Dislike of medication

• Distant pharmacies

• ASTHMA MANAGEMENT AND PREVENTION 53

Non-Drug Factors

• Misunderstanding or lack of instruction

• Fears about side-effects

• Dissatisfaction with health care professionals

• Unexpressed/undisclosed fears or concerns

• Inappropriate expectations

• Poor supervision, training, or follow-up

• Anger about condition or its treatment

• Underestimation of severity

• Cultural issues

• Stigmatization

• Forgetfulness or complacency

• Attitudes toward ill health

• Religious issues

Factors Involved in Non-Adherence

Asthma Adherence Pathway

Drug Factors

• Difficulties with inhaler devices

• Awkward regimes

(e.g.,four times daily or multiple drugs)

• Side effects

• Cost of medication

• Dislike of medication

• Distant pharmacies

• ASTHMA MANAGEMENT AND PREVENTION 53

Non-Drug Factors

• Misunderstanding or lack of instruction

• Fears about side-effects

• Dissatisfaction with health care professionals

• Unexpressed/undisclosed fears or concerns

• Inappropriate expectations

• Poor supervision, training, or follow-up

• Anger about condition or its treatment

• Underestimation of severity

• Cultural issues

• Stigmatization

• Forgetfulness or complacency

• Attitudes toward ill health

• Religious issues

Blue Cross Blue Shield DE Asthma Monitoring Program

“I start treatment without delay: Never”

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Patient name

Patient name

p

Patient Name

Patient Name beclomethasone

beclomethasone

albuterol

albuterol Patient name

Patient name

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• Select Appropriate Strategy:

• Steroid Phobia








Motivational Interviewing


What is Motivational Interviewing

• Patient –Centerd

• Focuses patient ambivalence

• Explores reasons for and against change

• Designed to enhance intrinsic motivation

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Paradigm Shift

Patient Must

Change

Move patient along

continuum of change

Help patient

to resolve

ambivalence

Build motivation and

confidence

Ambivalence

• Normal and understandable

• Any decision to change can have competing motivations, each of which has costs and benefits

• Strategy to help individuals examine, understand and resolve ambivalence to change

• Strategy to enhance a individual’s motivation to change

Exploring Ambivalence

Weigh the pros and cons of change

“What are some of the good things

about taking your medication?”

“What are some of the less good

things about taking your medication?”

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Initial Visit

ADHERENCE MANAGEMENT MODEL: Steroid Phobia

INITIAL VISIT

• History / PE

• Make recommendation

• Provide further rationale if recommendation not accepted

• Prescribe reasonable alternative if available

• Provide close supervision

MI Communications Strategies

• Reflections

• Cost-Benefit Analysis

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Reflective Listening

Statement, not a question

Let’s the patient know you are listening and trying to understand.

Ends with a down turn

Hypothesis testing

(If I understand you correctly, it sounds like..)

Take a guess at what the person means.

Affirms and validates

Keeps the client thinking and talking

Used strategically to elicit self-

motivational statements & diffuse

resistance

Reflective Listening

The words the

speaker says The words the

listener hears

What the listener

THINKS the speaker

means

What the speaker

means

Levels of Reflective Listening

Simple (Repeating) Reflection

– The simplest level. Merely repeat what the patient has said.

– . Mother: I am worried and frightened.

– Dr: So you’re worried and frightened.

End as a statement, not as a question

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Levels of Listening

Early/Small Jump

Restating Rephrasing Paraphrasing Deduction

Later/Big Jump

Levels of Reflective Listening

Simple (Repeating) Reflection

– The simplest level. Merely repeat what the patient has said.

– . Mother: I am worried and frightened.

– Dr: So you’re worried and frightened.

End as a statement, not as a question

Follow-up Visit

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Decision Balance Worksheet

Adherence to Meds

Costs Benefits

Tastes bad Sxs will go away

Hassle to

remember

Won’t have to go to

ER

Reminds me I

have asthma

Less sick days

Side effects Decrease need for

quick relief

Prevent asthma

episodes

Avoid long-term

damage

Non-Adherence to Meds

Costs Benefits

Feel worse Don’t have to

think about meds

Sleep better No hassle

Could get sick Don’t need in

summer

Can’t engage in

activities that I

like

ADHERENCE MANAGEMENT MODEL: Steroid Phobia

FOLLOW-UP VISIT • Clinical History on alternative treatment

• Patient education regarding treatment

• Motivational Interviewing Communication skills to overcome AMBIVALENCE

Summary

• Adherence to therapy is an important component to maximize outcomes and reimbursement

• An adherence management model has been shown to be effective in treating asthma patients

• Communication strategies are effective in promoting adherence

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Comparing Outpatient to Inpatient Asthma Rehabilitation*

11 Outpatient 22 Inpatient

ONE YEAR PRIOR **

Total Asthma Charges $6,374 ($6,319) $7,053 ( $5,640)

Hospital 3.91 (0 – 18) 5.09 (0 - 18)

ER 2.55 (0 – 6) 3.0 (2 - 12)

Corticosteroid Bursts 4.09 (2 – 10) 3.77 (2 - 12)

Length of Rehab (days) 4.82 (4 – 5) 14.05 (10 - 26)

ONE YEAR POST **

Hospital 0.09 (0 - 1) 0.64 (0 - 6)

ER 0.18 (0 - 1) 1.4 (2 - 6)

Corticosteroid Bursts 1.64 (0 - 4) 2.36 (0 - 10)

Rehab Physician Visits 0.5 (0 - 1) 9.45 (0 - 12)

P < 0.004

* Matched for 1-year prior morbidity

** Mean ( Median) Weinstein JACI 1998

Available Adherence Monitors

SmartInhaler

Source: http://www.smartinhaler.com/platform.html

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Propeller

Source: http://propellerhealth.com/solutions/

Gecko

Source: http://www.caretrx.com/#!/

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