10/24/2016. An Asthma Telehealth Program to Improve Adherence to Inhaled Corticosteroid Therapy. Disclosures. Overview of Presentation

Transcription

1 An Asthma Telehealth Program to Improve Adherence to Inhaled Corticosteroid Therapy 11 th 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 1

2 Asthma Treatment Mantra Correct Diagnosis Morbidity, Cost Correct Treatment QOL Adherence to Treatment Medical Reimbursement ADHERENCE OUTCOMES Fee for service - - Prior to 2017 Value / At Risk 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% 2

3 Merit-Based Incentive Payment System Source: 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 3

4 Mean Daily Adherence 10/24/2016 Mean Daily Adherence With ICS Intervention: Patient Feedback Standard asthma care Monitoring by MDI chronologs Treatment Control Direct clinician-to-patient feedback for treatment group 19 subjects RCT; single blind Week of Study Onyirimba et al. Ann Allergy Asthma Immunol. 2003;90: 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 4

5 Dulera Adherence Ongoing Study 40 persistent adult asthma 20 control/ 20 intervention Asthma Control Questionaire > 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 ) Provides analysis and objective monitoring: why patients don t adhere to Rx PATIENT PORTAL PROVIDER PORTAL Patient login Provider login Step 1: Real time objective adherence monitoring (preventative/res cue) Step 2: Patients self-identify barriers to Rx with validated survey Step 3: Clinicians identify hi-risk patients and Survey data respond with clinical decision support strategies Step 4: In-person and remote communications training: Shared- Decision-Making and Motivational interviewing Extensive library of digital and video educational resources addresses barriers to adherence identified in survey Adherence strategies supported with robust guidelines and literature links Asthma Outcomes When Theophylline Monitoring Severe Asthmatic Children After Intensive Rehabilitation Total Cost (dollars) 1 Year Prior Median (5-95 Pctl.) n=59 $10,240 (1,874-27,964) 1 Year Post Median (5-95 Pctl.) n=59 $4,036 (1,696-13,450) 2nd Year Post Median (5-95 Pctl.) n=59 $2,801 (940-8,625) 3rd Year Post Median (5-95 Pctl.) n=57 $2,316 (450-8,425) 4th Year Post Median (5-95 Pctl.) n=51 $1,936 (340-7,311) Inpatient Days 7 (0-25) 0 (0-6)* 0 (0-4)* 0 (0-4)* 0 (0-4)* Emergency Care Corticosteroid Bursts Physician Visits 4 (1-11)* 0 (0-5)* 0 (0-5)** 0 (0-2)* 0 (0-2)* 2 (0-9) 2 (0-8) 1 (0-5)* 1 (0-4)* 1 (0-5)* 2 (3-24) 2 (0-11) 1.5 (0-8) 2 (0-8) 2 (0-8) Weinstein et al. JACI. 1996;98: *P<0.001 **P<0.01 5

6 ASTHMA ADHERENCE MANAGEMENT PROVEN OUTCOMES Diagnose Adherence Status Identify Barriers Select Appropriate Strategy Optimize Communication Skills 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:

7 Nonadherence is associated with increased risk of disease exacerbations Milgrom H, Bender, B, Rand, C., J Allergy Clin Immunol, 1996: ASTHMA ADHERENCE MANAGEMENT PROVEN OUTCOMES Diagnose Adherence Status Identify Barriers Select Appropriate Strategy Optimize Communication Skills Weinstein JACI:IP

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9 Factors (Barriers) Involved in Non-Adherence GINA 2008 Drug Factors Non-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 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 Non-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 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 9

10 Patient name p Patient name beclomethasone Patient Name beclomethasone Patient Name albuterol Patient name albuterol Patient name 10

11 ASTHMA ADHERENCE MANAGEMENT PROVEN OUTCOMES Diagnose Adherence Status Identify Barriers Select Appropriate Strategy: Steroid Phobia Optimize Communication Skills Weinstein JACI:IP 2013 ASTHMA ADHERENCE MANAGEMENT PROVEN OUTCOMES Diagnose Adherence Status Identify Barriers Select Appropriate Strategy Optimize Communication Skills Motivational Interviewing What is Motivational Interviewing Patient Centerd Focuses patient ambivalence Explores reasons for and against change Designed to enhance intrinsic motivation 11

12 Paradigm Shift Move patient along continuum of change Patient Must 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? 12

13 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 13

14 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 selfmotivational statements & diffuse resistance Reflective Listening The words the speaker says The words the listener hears What the speaker means What the listener THINKS 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 14

15 Levels of Listening Early/Small Jump Later/Big Jump Restating Rephrasing Paraphrasing Deduction 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 15

16 Decision Balance Worksheet Adherence to Meds Costs Benefits Non-Adherence to Meds Costs Benefits Tastes bad Hassle to remember Reminds me I have asthma Side effects Sxs will go away Won t have to go to ER Less sick days Decrease need for quick relief Prevent asthma episodes Avoid long-term damage Feel worse Sleep better Could get sick Can t engage in activities that I like Don t have to think about meds No hassle Don t need in summer 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 16

17 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) (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 < * Matched for 1-year prior morbidity ** Mean ( Median) Weinstein JACI 1998 Available Adherence Monitors SmartInhaler Source: 17

18 Propeller Source: Gecko Source: 18