ADHERENCE…
WHERE’S THE APP
FOR THAT?
Kristin A. Riekert, PhD
Associate Professor
Co-Director, Johns Hopkins Adherence Research Center
DISCLOSURES
Gilead
 Consulting, medical affairs advisory program
Novartis
 Consulting
Cystic
Fibrosis Foundation
 Institutional contract to conduct the iCARE adherence
study
NIH
 Institutional contract to conduct the BALANCE
adherence study
A VISION FOR THE FUTURE
Is our job
done?
THE EXPERTS
DEBUNKING MYTHS
&
SCOPE OF THE
PROBLEM
ADHERENCE BY DRUG
NACFC 2012 Poster #464
ADHERENCE BY AGE
NACFC 2012 Poster #464
# PRESCRIBED PULMONARY
MEDICINES
Each individual drug’s MPR increases with the # prescribed pulmonary medications
NACFC 2012 Poster #464
IMPACT OF NONADHERENCE
Courses of IVs
Lung Function
100
MPR = 80-100% n = 28
MPR =50-80 %
100
MPR <50%
n = 36
80
95
90
60
+0.53%
40
FEV1% Predicted
85
20
Composite MPR
n = 31
80
-2.22%
75
70
-0.39%
65
0
60
0
1-2
3+
55
Courses of IVs
50
Eakin et al. JCF 2011, 258-264
Quarter 1
Time
Quarter 4
ALL-CAUSE INPATIENT COSTS
Controlling for: gender, age, comorbidities, index year, number of unique pulmonary medications
dispensed and average monthly drug copay at baseline.
NACFC 2012 Symposium #18
WHY IS ADHERENCE
SO CHALLENGING?
HOW COMPLICATED CAN IT BE?
Individual
•
•
•
•
•
•
•
Family
Age
Gender
Health Literacy
Disease & Treatment Knowledge
Mental Health/Behavioral Problems
Coping Style
Health Beliefs & Perceptions
•
•
•
•
•
•
•
•
Family Structure
Income/Health Insurance
Disease Knowledge
Mental Health/Behavioral Problems
Coping Style
Health Beliefs & Perceptions
Relationship quality
Involvement in care
ADHERENCE
Health Care System
•
•
•
•
•
•
Access to Care
Continuity of Care
Patient-Provider Communication
Shared Decision Making
Frequency of Clinic Visits
Provider Biases
Community
•
•
•
•
•
Neighborhood
Work (Hours & Policies)
School
Peer Support
Illness Stigma
Adapted from Modi et al., Pediatrics 2012, e473-85
80
60
20
40
p=.17
0
Knowledge Scores
100
KNOWLEDGE
NON-ADHERENT
ADHERENT
EDUCATION ISN’T ENOUGH
 Education  Control
CF-Nutrition Knowledge
* p< .05
Weight
Watson et al. J Am Diet Assoc 2008: 847-52
DEPRESSION PREVALENCE
•
The TIDES Study (N=1159)
• Adolescents (12-<18) = 22%
• Young adults (18-<35) = 13%
• Older adults (35-73) = 21%
Unpublished data courtesy of
Alexandra Quittner, PhD & Michael Schechter, MD
(TIDES PIs)
Proportion Screening Positive
DEPRESSION
NON-ADHERENT
ADHERENT
KEY TREATMENT BELIEFS
10
9
8
7
6
5
3
1
1
ADHERENT
On a scale of 1
to 10, how
confident are you
that youp<.01
can take
your medicine
when…?
2
2
3
2
1
NON-ADHERENT
SELF-EFFICACY
4
9
8
7
6
5
4
On a scale of 1
to 10, how
motivated are
you to take
your
p=.06
medicine every
day?
3
4
5
6
7
8
9
10
On a scale of 1
to 10, how
important do you
think it is to take
p=.03
your medicine
every day?
MOTIVATION
10
IMPORTANCE
NON-ADHERENT
ADHERENT
NON-ADHERENT
ADHERENT
WHAT CAN WE DO TO
SUPPORT
ADHERENCE?
“MULTI-COMPONENT”
INTERVENTIONS ARE BEST
 Education
 Directly Observed
 Reminders/Cueing
Therapy
 Social Support
 Parent-Training
 Family Therapy
 Cognitive Behavioral
Therapy
 Motivational
Interviewing
 Self-Monitoring
 Tailoring the Regimen
 Health & Behavioral
Feedback
 Problem-Solving
 Contingencies &
Rewards
Haynes et al. Cochrane Database of Systemic Reviews 2008
Kahana et al. J Pediatr Psychol. 2008:590-611
EDUCATION + BEHAVIORAL
 Behavioral + Education  Education
Caloric Intake
Weight
**
* p< .01; ** p<.001
*
Stark et al. Arch Pediatr Adolesc Med 2009: 915-21
ONGOING TRIALS
BALANCE
(PI: Riekert)
 Motivational Interviewing vs. Problem-Solving
iCARE
(PIs: Quittner & Riekert)
 CF My Way vs. Standard Care
CFFone
(PI: Quittner)
 Social Networking vs. Standard Care
Be-In-CHARGE!
(PI: Stark)
 Translation of FTF intervention to web-based
WHAT ARE OUR NEXT
STEPS?
TWO PLACES TO START
Accurately
Explore
identify who is nonadherent
ways to make interventions
more practical for patients, families and
care teams
THE CHALLENGE
PATIENT REPORT
PROVIDER REPORT
0
Daniels et al. Chest 2011; 425-32
OBJECTIVE MONITORING
OPPORTUNITIES
www.healthcare.philips.com
www.gentag.com
LEVERAGING TECHNOLOGY
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, 2011
Adult data: The Pew Research Center’s Internet & American Life Project, April 26-May 22, 2011
As of April 2012
there were over
13,600 health
apps for the
Apple iPhone –
<2% target
medication
adherence.
-mobihealthnews
July 2012
WHY CONSIDER HEALTH APPS?
Appealing
to our patients
Convenient
for patients
Cheaper
Disseminable
CF-NOTEBOOK APP
• Diary function
to log activities
Screen Shots Courtesy of Michael Marciel
MANGO HEALTH
• Log activities
• Reminders
• Compare to others
on same drug
• Incentives—points,
discounts &
rewards
Not
on the market yet
SPIROSMART MONITOR
Ubiquitous Computing (UbiComp) Research lab led by Shwetak Patel, University of Washington
PERSONALIZED FEEDBACK
Unpublished data courtesy of Dr. Noah Lechtzin, Johns Hopkins School of Medicine
OPPORTUNITIES
Capitalize
on real-time data
collection & feedback
Gamification
 Rewards
 Status
 Competition
 Altruism
Social
Networking
Dynamic
& changing
Nike Training Club app
IN THE MEANTIME…
DO
assess adherence at each visit
 Pharmacy records
 Patient 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 adherence
What makes it challenging to follow your treatment plan?
DO
problem-solve with the patient
DO
partner with mental health professionals
SUMMARY
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
A VISION FOR THE FUTURE
Is our job
done?
OUR JOB IS JUST BEGINNING
ACKNOWLEDGEMENTS
My Mentors :
 Dennis Drotar, PhD
 Cynthia Rand, PhD
 Alexandra Quittner, PhD
JHARC Faculty & Staff
 Michelle Eakin, PhD
 Marisa Hilliard, PhD
 Alana Ridge
 Andrew Bilderback, MS
 Angela Green
 Suzanne Lawson
 Devin Rand-Giovanetti
 Anthony Stanfield
 Many more…
The CF Experts
 Chase
 Katherine
 Megan
 Melissa
The Johns Hopkins
Pediatric & Adult CF
Care Teams
My Awesome Family
 Keith
 Andy
 Cooper