Improving Chronic Inhaler Adherence in Adolescent Populations
1. Improving Chronic Inhaler Adherence
in Adolescent Populations
By: Nicholas Gast, Heather Goodwin, Catherine Smith,
Kimhouy Tong, Mitchell Tucci
2. Before we begin….
-SMS (Short Message Service)
-Chronic vs. Acute Asthma
-Maintenance vs. Rescue inhalers
3. Presentation Goals
-Demonstrate the need for an intervention program for
adolescents with chronic asthma
-Describe the innovation and logic behind our texting
program
-Develop the implementation, cost, data collection and
analysis and overall expectations of the proposed program
-Examine future directions and gain your valuable insights!
Please hold all questions until the end of the presentation
4. Adolescent asthma
-Asthma is a leading chronic illness among children and
adolescents
-Rates of Asthma in children and adolescents are increasing
worldwide (Woolcock et al., 1997)
-21% of U.S. high school youths were at one time diagnosed
with asthma (CDC YRBS, 2013)
5. -Medication adherence rates decline throughout adolescence:
-Forgetfulness to take maintenance inhaler seen as major reason
for nonadherence
-Parents were perceived as the main reminding force
-Lack of perceived need or beneficial effects (Koster et al., 2015)
-Previous research has examined web-based interventions for
chronic medication adherence (Base et al., 2015)
-Very preliminary and qualitative
Teens and medication adherence
6. Objective
Implement an SMS-based program for a community
pharmacy setting that directly reminds adolescents to 1)
take prescribed medication for chronic asthma and 2)
respond post-administration
Aims:
-Decrease forgetfulness
-Increase involvement in self-management
-Improve adherence and thus quality of life
7. Significance and Innovation
-Target population is notoriously nonadherent (Koster et al., 2015)
-First study examining the efficacy of two way texting on chronic
medication adherence in an adolescent population
-New approach to increase perceived control of asthma
8. Pilot Design: Site Selection
- Site: Community pharmacy
- Major source of primary care
- Easily accessible for patients
- Find sites with high customer loyalty
- Patients will purchase medications
only from this site
- Ensures comprehensive pharmacy
profiles for data analysis
9. Pilot Design: Recruitment
- Recruitment: adolescents with chronic asthma ages 13 - 17
- Rationale: 78% American children ages 12-17 own cell
phones (Madden et al., 2013)
- Adolescents picking up steroidal inhalers will be invited
to join pilot
- Retention: those who complete study will be eligible for
raffled prizes
- itunes/google play gift cards, ipad
10. Pilot Design: Cost Analysis
- The majority of teenagers have cell
phones already
- Participation will only be available to
those with a mobile device
- In a study using SMS to improve
diabetic medication use average cost
per SMS was 70 cents (Haddad et al.,
2014)
- Possible vendor solutions...
12. Pilot Design: Payer Incentive
Where is the incentive for profit?
- Community pharmacy: increased
adherence → increased dispensing
- Insurance company: steroidal
inhalers directly help limit asthma
exacerbations that lead to emergency
room visits--Higher emergency
department visit rates in children and
adolescents compared to adults
(Akinbami et al., 2012)
13. Data Collection and Analysis
-Patients will respond to SMS
prompt and information will be
relayed back to the pharmacy
-responses will be catalogued and
utilized to determine the patient’s
adherence
-actual adherence will have no
effect on whether the patient is
eligible for prizes
14. Data Collection and Analysis
-If patient responds an automatic reply will be generated
informing them they are entered to win a prize
-Each response earns additional entries to win
-Pre-existing inhaler dose-counters will be utilized to
measure adherence, in addition to text responses
-Parents will be encouraged to bring old inhalers to the
pharmacy during refill for analysis
-Returned inhalers will be incentivized with coupons for
savings
15. Data Collection and Analysis
At the conclusion of the test period, an anonymous survey
will be distributed to collect further information
-Anonymous aspect may allow for more truthful answers
-The pharmacy can utilize the survey to discover the patient’s
attitude toward the program and what are the patient’s
perceived roadblocks to adherence
All collected data will then be statistically analyzed to
determine if the program is successful in increasing
adherence among the participants
16. Expectations
-Increase medication adherence in
adolescents using steroidal inhalers
chronically
-Increase the the quality of life of patients
by increasing their ability to participate in
activities with peers
-Provide benefits to insurance companies
by reducing cost (Altman, 2011)
17. Why are the Results Expected?
-Approximately 78% of adolescents ages 12-17
have a cell phone (Madden et al., 2013)
-63% say they exchange text messages every
day, surpassing the frequency of all other
communication forms (Lenhart, 2012)
-Adolescents are already comfortable with cell
phone monitoring and identify SMS messaging
as their preferred method of contact
18. Potential Limitations
-Truthfulness of adolescents
-Lack of involvement of parents
-Lack of involvement by
pharmacists
-Could be identified by
administering an anonymous survey
Example Survey
19. Alternative Approaches
-The parent(s)/guardian could also receive
a two-way SMS message
-Send automatic alerts to the pharmacists
notifying them of missed doses once the
adolescent has not responded
-To overcome the potential limitation of the
time of day that the SMS is sent, a reminder
message could be sent at a later time during
the day
20. Future Directions
1. Broaden the scope of clinical indications served to
include other chronic medication schedules
-E.g. Insulin in Type I Diabetes (“Juvenile Diabetes”)
2. Increase the accessibility of the 2 Way SMS System
-Low literacy: text picture of medicine as a reminder
-Translate texts into commonly spoken languages (e.g.
Spanish)
21. Future Directions
3. Develop multi-media platform
to include health network and
social network
-Reinforces adherent
behavior with peer support
22. Summary
- 2 Way SMS: Text reminders that prompt users to send a
response text after taking their medications
-This pilot could serve as a template for other medication
regimens that are temporally sensitive
-This strategy can potentially improve chronic medication
adherence in tech savvy populations such as adolescents
24. Questions?
Some things to consider…
-What other patient groups could benefit from 2 Way SMS?
-How could we incorporate social media into the program?
25. References
Washington State.(2013). “How Asthma Affects the Qaulity of Life in Youth Avaliable at
http://www.doh.wa.gov/Portals/1/Documents/Pubs/345-332-QualityOfLife.pdf. Accessed on July, 21,2015.
Lv, Yanhua,Zhao, H., et al. (2014). A Mobile Phone Short Message Service Improves Perceived Control of Asthma: A Randomized Controlled
Trial. Telemedicine and e-Health, 18, 420-426 doi: 10.1089/tmj.2011.0218
Greenwood, V. Why are asthma rates soaring?. In: Scientific American. April 2011. Accessed July 31, 2015.
http://www.scientificamerican.com/article/why-are-asthma-rates-soaring/?page=3
Bass, A. M., Farhangian, M. E., & Feldman, S. R. (2015). Internet-based adherence interventions for treatment of chronic disorders in
adolescents.Adolescent Health, Medicine and Therapeutics, 6, 91–99. doi:10.2147/AHMT.S56065
American Lung Association, Epidemiology and Statistics Unit, Research and Program Services. Trends in Asthma Morbidity and Mortality.
January 2009.
Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010.
NCHS data brief, no 94. Hyattsville, MD: National Center for Health Statistics. 2012.
Haddad Nazar S., Istepanian Robert, Philip Nada, Khazaal Faris A.K., Hamdan Thamer A., Pickles Timothy, Amso Nazar, and Gregory John
W.. Diabetes Technology & Therapeutics. July 2014, 16(7): 454-459.
Centers for Disease Control and Prevention. 2013 Youth Risk Behavior Survey. Available at: www.cdc.gov/yrbs. Accessed on July 31, 2015.
Weisskirch, R.F. Parenting by Cell Phone: Parental Monitoring of Adolescents and Family Relations. Journal of Youth Adolescence. (2009)
38:1123–1139. DOI 10.1007/s10964-008-9374-8
Woolcock AJ, Peat JK. Evidence for the increase in asthma worldwide. In: The Rising Trends in Asthma. West Sussex:John Wiley & Sons Ltd;
1997 p. 122-139.
Editor's Notes
Bring the lecture on a flash drive
bring 4 extra copies of handout to presentation
215 Shillman for presentation
Rickels notes from class:
Reference according to the guidelines that Peter sends out via email
It’s important to get the idea of what the problem is, what has been done and why our idea is innovative is extremely important very early on
Be energetic and show that you are interested. Not showing passion can be problematic
Let your audience know what perspective you have taken. AKA let know know that we are in a COMMUNITY PHARMACY
No more than 20 minutes, can be less
Encourage audience that is they have questions to leave it for the end. Let them know right off the bat
PROFESSIONAL DRESS, YALL.
-Causes: microbial exposure, lifestyle changes, obesity? (Greenwood 2013)
From Rickles slide: this should take about 2-3 minutes
He likes the government sites
State the topic of your presentation; what is the problem you are exploring
Why is the problem important- timely, important to patient outcomes and how?
What are the goals and objectives of your presentation?
Identify necessary terms that you will be using in your presentation
From Rickles Slide: This should take about 5 minutes?
Nature of the communication problem (frequency and extent)
Reasons for the problem
Relevant literature/background identifying problem
Previous strategies to reduce the problem (if available)
“Long term goal of this work is…”
-Validation and expansion of finding in adult asthmatic populations utilizing 1-way texting as an intervention (Lv et. al., 2014)
How would you and/or think others would use the information learned from your intervention program to guide future work in the area?
What might be future directions/ recommendations based on the topic?
Nonadherence has many contributing factors!
Modify 2 Way SMS to address other issues underlying non-adherence
-Lack of perceived need: Include motivational messages and milestones
Could also address low levels of health literacy
What are the key points that you want your audience to come away with? Why is your program worthwhile?
Interesting to consider that this model is actually shown to be successful in economically deprived countries, in which mobile telephone is their main source of communication
