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Unpublished data courtesy of Alexandra Quittner, PhD & Michael Schechter, MD (TIDES PIs)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