Kristin A. Riekert, PhDAssociate ProfessorCo-Director, Johns Hopkins Adherence Research Center

ADHERENCE…

WHERE’S THE APP FOR THAT?

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

A VISION FOR THE FUTURE

Is our job done?

THE EXPERTS

DEBUNKING MYTHS &

SCOPE OF THE PROBLEM

NACFC 2012 Poster #464

ADHERENCE BY DRUG

NACFC 2012 Poster #464

ADHERENCE BY AGE

# PRESCRIBED PULMONARY MEDICINES

Each individual drug’s MPR increases with the # prescribed pulmonary medicationsNACFC 2012 Poster #464

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

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

WHY IS ADHERENCE SO CHALLENGING?

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

KNOWLEDGE

020

4060

8010

0K

no

wle

dg

e S

core

s

NON-ADHERENT ADHERENT

p=.17

WeightCF-Nutrition Knowledge

EDUCATION ISN’T ENOUGH

Education Control

Watson et al. J Am Diet Assoc 2008: 847-52 * p< .05

• 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Unpublished data courtesy of Alexandra Quittner, PhD & Michael Schechter, MD (TIDES PIs)

DEPRESSION

NON-ADHERENT

ADHERENT

Pro

port

ion

Scr

eeni

ng P

ositi

ve

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

WHAT CAN WE DO TO SUPPORT

ADHERENCE?

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

Caloric Intake Weight

EDUCATION + BEHAVIORAL

Behavioral + Education Education

***

* p< .01; ** p<.001 Stark et al. Arch Pediatr Adolesc Med 2009: 915-21

ONGOING TRIALS

WHAT ARE OUR NEXT STEPS?

TWO PLACES TO START

Accurately identify who is nonadherent

Explore ways to make interventions more practical for patients, families and care teams

THE CHALLENGE

0

PATIENT REPORT PROVIDER REPORT

Daniels et al. Chest 2011; 425-32

OBJECTIVE MONITORING OPPORTUNITIES

www.gentag.com

www.healthcare.philips.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, 2011Adult 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

Screen Shots Courtesy of Michael Marciel

• Diary function to log activities

Not on the market yet

MANGO HEALTH

• Log activities

• Reminders

• Compare to others on same drug

• Incentives—points, discounts & rewards

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

GamificationRewardsStatusCompetitionAltruism

Social Networking

Dynamic & changing Nike Training Club app

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…

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

A VISION FOR THE FUTURE

Is our job done?

OUR JOB IS JUST BEGINNING

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