Improving statin adherence through interactive voice technology & barrier breaking communications

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Care Continuum Alliance presentation from 2010 given with Kaiser about use of IVR in pharmacy adherence.

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Improving statin adherence through interactive voice technology & barrier breaking communications

  1. 1. Improving Statin Adherence through  Interactive Voice Response (IVR) Technology  & Barrier Breaking Communications Ananda Nimalasuriya, MD Chief of Endocrinology Kaiser Permanente Riverside California George Van Antwerp, MBA General Manager of Pharmacy Solutions  Silverlink Communications
  2. 2. Learning Objectives • Understand the key barriers to statin adherence • Learn how IVR communications can be  leveraged to drive statin adherence and address  specific barriers • Learn how to use continuous quality  improvement for better communications  effectiveness 2
  3. 3. Agenda • The long‐term impact of controlling blood  cholesterol levels – The dangers and prevalence of high cholesterol – The impact on clinical outcomes and cost – The importance of statins in lowering and controlling  cholesterol – The challenge of non‐adherence to statins 3
  4. 4. Agenda (cont’d) • Statin Adherence Program – Hypothesis & goals – Program tactics & details – Program results & barrier survey • The Impact of IVR Technology – Using personalized communications – Collecting barrier information to deliver targeted educational  messages – Leveraging champion / challenger to improve outcomes • Q&A 4
  5. 5. If medication adherence was a  disease, it would be an epidemic. The estimated annual costs of    non‐adherence is $290B.  Source: NEHI, 2009 5
  6. 6. High Cholesterol & Atherosclerosis Coronary heart disease • Stable angina, acute myocardial infarction, sudden death,  unstable angina Cerebrovascular disease • Stroke, TIAs Peripheral arterial disease • Intermittent claudication, increased risk of death from heart  attack and stroke CHD risk equivalents • • • Other clinical forms of atherosclerotic disease (abdominal  aortic aneurysm, symptomatic carotid artery disease) Diabetes Multiple risk factors that confer a 10‐year risk for CHD >20% 6
  7. 7. Major Causes of Death in the U.S. Source: NCHS Deaths: Final Data for 2007   7
  8. 8. _______________________________________________________________________________ Lifetime Risk of CHD Increases with  Serum Cholesterol Cholesterol Level Source:  Framingham Study: Subjects age 40 years DM Lloyd‐Jones et al Archives Internal Medicine 2003; 1966‐1972 8
  9. 9. Population vs. High‐Risk Approach 10 Percent of Population Percent of Population 10 8 6 4 2 0 200 300 Serum Cholesterol Level (mg/DL) • • • 6 4 2 0 100 • 8 400 100 200 300 400 Serum Cholesterol Level (mg/DL) Risk factors, such as cholesterol or blood pressure, have a wide bell‐shaped distribution, with a “tail”  of high values. The “high‐risk approach” involves identification and intensive treatment of those at the high end of  the “tail”, often at greatest risk of CVD, reducing levels to “normal”. Most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur  among those in the “average” risk group. Significant reduction in the population burden of CVD can occur only from a “population approach”,  shifting the entire population distribution to lower levels. 9
  10. 10. Relationship Between LDL‐C Levels  and Event Rates in Statin Trials Event (%) 25 LIPID 5 TNT (atorvastatin 80 mg/d) 90 TNT=Treating to New Targets; HPS=Heart Protection Study CARE=Cholesterol and Recurrent Events Trial LIPID=Long‐term Intervention with Pravastatin in Ischemic Disease 4S=Scandanavian Simvastatin Survival Study 170 Source:  NLEC (National Lipid Education Council 10
  11. 11. We Know Statins Work. What’s The Challenge? Medication Adherence “The degree to which the person’s  behavior corresponds with the  agreed recommendations from a  health care provider.”  – World Health Organization 11
  12. 12. 12
  13. 13. Medication Adherence 22% of U.S. patients take less of the medication than is prescribed American Heart Association: Statistics you need to know.  http://www.americanheart.org/presenter.jhtml?identifier=107 Accessed November 21, 2007. 13
  14. 14. Statin Adherence After 2 Years By  Condition Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy  in elderly patients with and without acute coronary syndromes. JAMA 2002;288:462‐467 14
  15. 15. But Does it Matter? Would Anything Get Better with More Adherence? Results of failure to adhere to  prescribed medications:  Increased hospitalization Poor health outcomes Increased costs Decreased quality of life Patient death -60% RR Dudl, R.J., Wang, M.C., Wong, M., & Bellows, J.  (2009)  Preventing Myocardial Infarction and Stroke With a  Simplified Bundle of Cardioprotective Medications. American Journal of Managed Care 15
  16. 16. Impact of Improved Adherence “Increasing the effectiveness of adherence    interventions is likely to have a far greater impact on population health… than any improvement in medical  treatments, including highly promising  advances in biomedical technology”. –World Health Organization (WHO) report, Adherence to Long‐Term Therapies: Evidence for Action. 2003 16
  17. 17. Medication Adherence: Complex  Behavior With Many Barriers Patient Provider Healthcare  System PATIENT CAUSES FOR NON ADHERENCE Complex therapies Side effects Failure to understand the need for  the medication High out‐of‐pocket costs Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Ref: Osterberg, NEJM, 2005 Long‐term persistence in use of statin therapy in elderly patients.  JAMA 2002;288:455‐461  17
  18. 18. Evidence‐Based Strategies for  Improving Statin Adherence Effective Interventions Patient reinforcement and reminding Patient information and education Simplification of drug regimen Reminding patients seems the most  promising intervention to increase  adherence to lipid lowering drugs. Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004371. DOI: 10.1002/14651858.CD004371.pub3 18
  19. 19. Southern California Kaiser Statin  Adherence Program Objectives Initial Steps • Interactive yet cost effective • Literature review – If interaction is needed, it has to  • Survey target population be mostly automated • Develop IVR messaging in  • Sustainable and scalable to all  collaboration with Silverlink: of Kaiser Southern California – PDCA cycles to improve the  • Universally applicable ‘listen’ rate – Computer & reading literacy – Cultural & language sensitive – Individualized communications – Address barriers to adherence • Increase adherence and  improve clinical outcomes 19
  20. 20. Southern California Kaiser Statin  Adherence Program Personalized Outreach To easily switch to the convenience of mail order Integrated  Customer  Service IVR  Reminder  Calls Barrier  Survey To reach & engage the healthcare consumer Educational  Materials To reinforce the importance of adherence to statins To identify causes of non adherence 20
  21. 21. Statin Adherence Program  Evolution Identify  Issue Survey For  Barriers Phase I Test Intervention Launch  Program &  Analyze Phase II Scale  Integrate  Segment … Future 21
  22. 22. Statin Adherence Program Details • Target: Patients taking statins Diabetes or cardiovascular disease Filled 100‐day prescription 120‐140 days since last fill • Timeline: December 2007 to November 2008 (program) March 2008 to August 2008 (claims) • Location: Riverside Medical Center in S. California • Communications Strategy: Interactive automated phone calls Personalized and HIPAA‐compliant messages Educational and barrier‐breaking messaging • Policies: Calls 10AM‐12PM (Medicare); 7‐8:30PM (Com) 3 attempts on 3 different days; answering  machine messages left 22
  23. 23. An Emphasis on Messaging • Messaging: Educational messages on the importance of statin medication as a life‐long medication Question about intent to refill Options to hear about a convenient way to refill their medications (mail order) Questions to determine the personal barriers to adherence for those who reported that they  were unsure or did not intend to refill – Suggestions around how to address personal barriers – – – – • Improvements and Changes Implemented: – – – – – – Initially offered a transfer to a KP Pharmacist Shortened the dialog to improve the engagement rate Simplified the educational messaging to address health literacy Changed the targeting from new users to focus on gaps‐in‐care Added messaging to set expectations – “this will only take a minute or two” Added a barrier survey with succinct suggestions to address some of the barriers 23
  24. 24. Kaiser Statin Adherence Calls Education & personalization Barrier Survey Mail order option 24
  25. 25. Statin Adherence Program Analysis  & Results 1000 900 800 700 600 500 400 300 200 100 0 88% Reachable 71% Heard Target Population Reachable Population Population That Heard  Message 25
  26. 26. The Impact of Targeted  Communications on Adherence Note: Analysis was based on claims filled within 3 weeks of final outbound call attempt. 26
  27. 27. The Power of Barrier Breaking  Messaging  27% of those who stated they had not intended to refill, did refill  their medication after listening to barrier‐breaking messages DID NOT KNOW COST 1-2-3 CONVENIENCE PROVIDER SIDE EFFECTS 27
  28. 28. Population Insights Key Barriers to Statin Adherence Cost 11% Physician  Instructions 15% Did Not  Know To  Refill 37% • 13% of those with side effects  eventually refilled • 42% of those with convenience  issues eventually refilled Convenience 15% Side Effects 22% N=233 Source:  Kaiser Silverlink Statin Adherence Barrier Survey 28
  29. 29. A Win‐Win: Mail Order Improves  Adherence 84.7% of patients who received their medications by  mail at least two‐thirds of the time stuck to their  physician‐prescribed regimen, versus 76.9% who  picked up their medications at “brick and mortar” Duru, O.K & Schmittdiel, J.A. (2010) Mail Order Pharmacy Use and Adherence to Diabetes‐Related Medications American Journal of Managed Care 29
  30. 30. IVR Technology Supports Statin  Adherence Program Scalable Efficient Personalized Effective Automated  Interactive  Calls Challenge:  How to blend reminders with pharmacy counseling in a predictable  way that leveraged research into motivational interviewing and health literacy. 30
  31. 31. Data‐Driven Opportunities Risk  Predictors Preferences One campaign with  many different  experiences: ‐Different channel ‐ Different “voice” ‐Different messaging ‐Different timing ‐Different sequencing Behavioral  Segments Past Behavior 31
  32. 32. Adaptive Control: Iterative Process  for Optimal Results • 42% • • 56% 49% Launch segment‐by‐segment  interventions Assess and measure success  rates and identify segment ‘champions’ Launch ‘challengers’ against  segments – Consistent process – Rapid experimentation – Randomized control group • Integrate learning into database  for continual improvement 32
  33. 33. Future • Continue to incorporate ‘learnings’ around  barriers • Better integration with pharmacy resources • Scale beyond Statins • Multi‐channel and multi‐touch strategies • Auto refill programs • Segmentation and custom messaging by  segment 33

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