Presentation by Avella Specialty Pharmacy & mScripts at Armada 2015 on improving medication adherence through mobile app technology. Learn about how Avella meets the challenges of medication non-adherence: http://www.avella.com/medication-adherence

1. IMPROVING HIV MEDICATION ADHERENCE
USING MOBILE HEALTH TECHNOLOGY
Fiona Smythe I mscripts
Eric Sredzinski, Pharm.D, AAHIVP I Avella Specialty Pharmacy

2. 2
PERCENT OF RETAIL PRESCRIPTIONS ABANDONED,
REJECTED AND REASONS FOR REJECTIONS, 2013
DISTRIBUTION OF PAYER REJECTION
REASONS IN SELECTED CLASSES
Almost 10% of the 3.6 billion retail prescriptions
written by physicians are NOT dispensed to patients
PrescriptionAbandonment and Payer Rejections

3. 3
• Patient Characteristics
• Health beliefs
• Quality of life/Health status
• Understanding of disease/Therapy
• Psychological state
• Social support
• SES status
• Forgetfulness and lifestyle factors
• Disease characteristics
PREDISPOSING FACTORS
• Complexity of regimen
• Food interaction
• Side Effects of regimen
• Schedule of regimen
• Cost of drug
• Cost of side-effects of treatment
• Cost of follow-up care
TREATMENT FACTORS
POSSIBLE INTERVENTIONS POSSIBLE INTERVENTIONS
Fig 1. Schematic of factors and barriers involved in adherence to targeted OAMs and possible ways to improve adherence.
ADHERENCE
&
PERSISTENCE
• Identify degree of adherence
• Use assessment tools
• Ask about barriers
• Keep an open non-confrontational dialogue
• Increase patient education at every visit
• Provide literature on side effects
• Refer to support groups, websites, and
disease specific organizations
• Involve physicians, nurses, pharmacists and
family members
• Multi-disciplinary approach
• The patient has a “team”
• Address Costs
• Use available assistance programs
• Help patients apply for necessary benefits
• Make sure refills are ordered in time
• Consider initiating nurse-led phone calls to
assess adherence, side-effects and any barriers
• Encourage tools to help with adherence
• Pill boxes, alarms, calendars, daily routines
SYSTEM FACTORS
• Interaction with M.D.
• Interaction with nurse
• Ease of drugs
• Satisfaction with care
Barriers toAdherence

4. 4
Cochrane Review, Oct, 2005;
Transplantation (2007;83:858-873)
Blood (2007;109:58-60)
Disease
Rates of non-
adherence
Epilepsy 30% to 50%
Arthritis 50% to 71%
Hypertension 40% (average)
Diabetes 40% to 50%
Oral
Contraceptives
8%
HRT 57%
Asthma 20%
Kidney Transplant 35.6%
Heart Transplant 14.5%
Liver Transplant 6.7%
CML (Imatinib) 25%
COMPLIANCE DECLINES WITH TIME
BenchmarkAdherence Rates

5. 5
Study population size Rates of adherence
N=17,573 patients from 33 studies 55% adherent
N=540 patients from 1 cohort 32.78% adherent
N=3,140 patients from 22 US studies 53%
Adherence defined as- 85-100% MPR or
viral suppression of <50 - <500 copies/ml
N=862 ART naïve patients 36% discontinued therapy
ARVAdherence

6. 6
Adapted from Maggiolo et al. Clin Infect Dis. 2005;40:158-63.
NNRTI = nonnucleoside reverse transcriptase inhibitor;
PI = protease inhibitor.
Relation BetweenAdherence and Treatment Failure

7. 7
$1.8 Billion
HIV
$105.4 BILLION TOTAL
AVOIDABLE COSTS BY DISEASE
IMS Institute for Healthcare Informatics, 2013
$44 Billion
Hypercholesterolemia
$24.6 Billion
Diabetes
$18.6 Billion
Hypertension
$15.5 Billion
Osteoporosis
$1 Billion
Congestive heart failure
HIV Cost of Non-Adherence

8. 8
Living with HIV: Patient Story

9. 9
http://www.ncbi.nlm.nih.gov/pubmed/19866536
http://www.ncbi.nlm.nih.gov/pubmed/16846321
BEHAVIOR AGE PRACTICES
Common Causes of Non-Adherence in HIV Populations

10. 10
Source:
http://pando.com/2014/03/17/validic-wants-to-send-your-health-data-straight-to-hospital/
http://www.informationweek.com/mobile/mobile-health-market-to-reach-$26b-by-2017/d/d-id/1110964?
http://www.pmlive.com/pharma_news/digital_health_charge_led_by_millennials_in_the_us_669123
The Accenture Connected Health Pulse Survey, 2012 & Mobile Health Market Report 2011–2016
4.3 million
mobile health application
downloads daily
$26 billion
predicted 2017 worldwide
mHealth market revenue
for associated services and
hardware
66%
of people would use a
mobile app to manage
a heart condition
72%
of patients want to
refill prescriptions on
their phone
Patients Want mHealth

11. 11
Overview of the Tool

12. 12
Timely two-way
messaging
Create an experience
that is intuitive, easy to
use and adds value for
patients
Real-time notifications
provide behavioral
“nudges”
Build on existing habits
• Reinforce good behavior
• Small, incremental modifications
Customized messaging
based on behavior
Stringent privacy practices
• Double-opt in text registration
• Data masking
Employing Best Practices

13. 13
Pharmacy
Management
System
Patient Portal
Mobile Pharmacy
App
360 visibility into patient data
Integrations between the dispensing system,
patient portals and mobile pharmacy apps
Real-time data provides insight into behavior
Understand risk and design interventions with
predictive analytics
mHealth Strategies in Specialty Pharmacy

14. 14
To
open: hold down tab &
tu
rn
Get
our mobile a
pp:
av
ella.com/ap
p
E-mails
avella.com on mobile
Pill bottles
Fax
In-store display
Print
Rollout Strategy: Marketing Touch Points

15. 15
PRIMARY
OBJECTIVES
• Proving efficacy of mobile to increase adherence
• Decreasing operational burden
• Validating systems integration
BARRIERS
• High consumer expectations set by retail apps
• HIPAA/HITECH, TCPA
• Strong feelings of “What’s in it for me” require intensive patient education
• Getting app onto patient’s phone & getting them to use it
ASSUMPTIONS • Multi-faceted program using mobile health
• Impact of mobile-optimized adherence tools
• Replicable for other hard-to-manage populations
AClinical Study Tests TheseAssumptions

16. 16
• On- and off-platform cohorts
• Brand name ARVs of interest
• Retrospective cohort PDC and survival analysis
Atripla, Complera, Intelence, Isentress, Kaletra,
Norvir, Reyataz, Stribild, Trizivir, Truvada
On-platform = 224 (10.6%)
Off-platform/control = 1,896 (89.4%)
• Study period of 12 months
• Possible self-selection bias
Methodology

17. 17
Female
14%
Male
85%
Non-
defined
Female
20%
Male
80%
ON-PLATFORM OFF-PLATFORM
GENDER
Female
14%
Male
85%
Did not self-
identify/identify
as male or
female 1%
Female
20%
Male
80%
Demographics

18. 18
ON-PLATFORM OFF-PLATFORM
AGE
Demographics

19. 19
< 1 year
(97%)
>1 year
(3%)
TIME SINCE PLATFORM REGISTRATION
Turned
on 221
(99%)
Turned
off 3 (1%)
REFILL REMINDER PREFERENCE
Measurements of Success:
Platform Engagement

20. 20
Zero 0
(0%)
One 11
(5%)
Two 173
(78%)
Three 37
(17%)
NUMBER OF ACTIVE
NOTIFICATION METHODS
None 0%
In-app
notification
47%Text
Message
43%
Email 10%
NOTIFICATION METHOD PREFERENCE
Measurements of Success:
Platform Engagement

21. 21
0.85
0.86
0.87
0.88
0.89
0.9
0.91
0.92
0.93
Off Platform On Platform
PDC
Off Platform On Platform
N=1,896
N=224
Measurements of Success:
Improved Patient Adherence

22. 22
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 10 20 30 68 85 97 111 123 134 151 163 173
ProportionofPatientsonTherapy
Days to Discontinuation
PATIENT DISCONTINUATION BY PLATFORM USAGE
Off-Platform
On-Platform
Patients on-platform were 2.9 times more likely to remain on therapy
Measurements of Success:
Patient Discontinuation

23. 23
Patients
with PDC => 90%
Measurements of Success:
High Viral Suppression Loads

24. 24
OPPORTUNITIES TO OPTIMIZE
ADHERENCE TOOLS THROUGH
MOBILE HEALTH
• Peer support forums
• Feedback through surveys
• Adverse event reporting
• Financial assistance based on perceived need
• Secure messaging, chat, or video
• Delivery of educational material
• Clinical trials – Researchkit
• Interfacing with EMR or patient portals
• Patient ownership and control of data
• Predictive analytics and interventions
Source: Fierce Mobile Healthcare
APPS WILL BECOME MORE
DISEASE SPECIFIC
• Deliver relevant information
based on condition and behavior
Continuous Improvement:
The Road Ahead for Mobile Adherence

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Eric Sredzinski, Pharm.D.
AAHIVP - EVP, Clinical Affairs & Quality Assurance
Pharmacy Program Director, ADAP
eric.sredzinski@avella.com
Fiona Smythe
Vice President, Strategy
fsmythe@mscripts.com
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