Objectives Identify the increasing applications of mobile - - PDF document

4/23/2019 1 Use of Mobile Health Technology for Medication Adherence

Chris Blosser May 4, 2019

Objectives

• Identify the increasing applications of mobile

technology in healthcare

• Explain the concept of Patient-Centered

Healthcare

• Assess the impact of medication nonadherence on

healthcare

• Review a pilot study of mobile healthcare

application in kidney transplant recipients

Conflict of Interests

• Funding commitment for Pilot Study – TapCloud, LLC

4/23/2019 2

Forbes.com; The International Telecommunication Union

4/23/2019 3

Patient Role in Healthcare

Institute of Medicine report, Crossing the Quality Chasm

Patient-centered care should be "respectful of and responsive to individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions.” (2001)

Patients are encouraged to take an active role in their own healthcare safety.

Patient Communication

• EMR-based Patient

Email

• UW Email
• Office phone calls
• Text messages
• Cell phone calls

On Mar 30, 2016, at 11:35 AM,

• Dear Dr. Blosser,
• As you probably know my wife, _______.

was hospitalized on the last Sunday and the kidney was transplanted on Monday, March 28th.

• This is very exciting news for our family after

6 years of not stop dialysis 3 times per week.

• _____ is recovering and they say everything

is going well and she may be discharged

• n the end of this week, possibly Friday.
• We would like to ask you ******. Please let us

know, [if] it is possible.

• Many thanks ****.
• Sincerely,

_______________________

Do Patients & Providers See Medical Technology the Same?

• 2508/21812 Medscape healthcare professional

members completed emailed 15 item survey

• 1102/456,243 consumers completed same survey
• Topics:
• New Medical Technology for self-diagnosis of non-life threatening

condition

• Privacy
• Medical Health Records
• Cost & Transparency
• Physical Exams & Imaging

Boeldt DL, et al. J Med Internet Res. 2015 Sep 14;17(9):e215.

4/23/2019 4 Who owns medical record & does patient access alter outcomes?

Boeldt DL, et al. J Med Internet Res. 2015 Sep 14;17(9):e215.

• Medicine is at it’s

“Gutenberg moment”

• Mobile internet ->

Digitized and Democratized healthcare.

• Shifting to patient-

directed data- gathering, analysis and intervention model, that may be cheaper.

4/23/2019 5

mHealth

24%

Research.technologyadvice.com

Eric Topol, The Creative Destruction of Medicine

Future Healthcare

Patient-Centered and Reported Care Mobile Technology Healthcare System

• (image of fraying end of rope)

4/23/2019 6

Real World Usage of mHealth Monitoring Device

• 3872/4525 completed the crowdsourced email

inviting participation in use of multi-parameter vital sign monitor.

• Aim: Identify factors associated with consistent

long-term use of the monitor.

Waalen J, et al. (2019) PLOS ONE 14(4): e0215468.

Amount of device usage by total time in study.

Consistent Long-Term Use [>26 wks, 3x/wk, >80% wks]

• Older adults
• No children at home
• Use other medical devices

Waalen J, et al. (2019) PLOS ONE 14(4): e0215468.

Risks with Revolution

• Privacy risks – 43% of identity theft via healthcare

records in 2013

• All digitized equipment is at risk of data theft or

cyber attack, including pacemakers and dialysis machines

• With autonomy comes

personal responsibility

4/23/2019 7

Reasons for Nonadherence

Walgreen Co, 2014; https://www.hlc.org/wp-content/uploads/2014/05/Walgreens-Slides.pdf

• Active Nonadherence
• Passive Nonadherence

“Drugs don’t work in patients who don’t take them.” C. Everett Koop

Osterberg L, Blaschke T. NEJM 2005

Impact of Nonadherence

https://www.hlc.org/wp-content/uploads/2014/05/Walgreens-Slides.pdf

4/23/2019 8

Osterberg L, Blaschke T. NEJM 2005

Patient vs Medical- Centered Outcomes

• Solid organ transplantation has improved

recipients’ survival quality of life (QoL) dramatically.

• Yet, kidney transplant recipients have lower QoL

scores compared with their healthy peers.

• Providers measure transplant outcomes with

quantitative measures

• Organ recipients commonly measure transplant
• utcomes in qualitative measures, i.e. how they

feel, incl. how medication regimen affects day- to-day function.

Young Adult KTRs at Risk

• 22yo male, ESRD of unknown etiology s/p DDRT 2007
• Baseline Scr 1.4
• Presented 3/2015 with Scr 2.1
• Admitted not taking meds consistently
• Started drinking

Etoh regularly

• Why?

4/23/2019 9

Young Adulthood

• Physical, cognitive, social & psychological

development

• Preoccupation with body image
• Identity search
• Questioning authority
• Risk Taking
• Substance abuse
• Suicide

Chronic Illness & Youth

• Don’t fit into common paradigm of transplant care
• Compete with ever-aging population
• Isolated from peers, both healthy & those with same

medical conditions

Perry EE. Renal Fail 2011

Young Adult Graft Survival

5-year Graft Survival Among Living Donor Adult Kidney Transplant Recipients, 2009

• Over 90% of18-34yr old

KTRs are alive at 5 years but the 10-year survival is much less favorable.

• Adjusted 5-year graft

survival for this age group is lower than

• lder cohorts.

Figure KI 5.4. 2014 OPTN/SRTR Annual Report

4/23/2019 10

Intrapatient Variability

• Within-Patient

Variability in Tacrolimus Blood Levels Predicts de novo DSA, antibody-mediated rejection and kidney graft Loss.

Rodrigo E, et al. Transplantation 2015

CV < 30% CV > 30%

Allograft Survival: Late acute rejection free time

Vlaminck, H., et al., American journal of transplantation, 2004. 4(9): p. 1509-13.

Adherence Interventions

• Standard of care for Kidney Transplant Recipients

includes regular clinic visits and adherence education, yet there is much room for improvement.

• Many age-specific interventional tools are available

for improving adherence in the kidney transplant population.

4/23/2019 11

Adherence Interventions

• Large majority (85%) of young adults in U.S. are

smartphone owners

• ~75% of 18-29yr olds used their phone in the last

year to access health information

• Potential for healthcare applications and mHealth is

intuitive.

Pew Research Center, http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/

TapCloud Application

• Patient-oriented

application that

• Integrates patient-reported

information,

• Medication reminder system
• Patient-provider

communication link.

• Functions allow

patients and their care teams to plan, track, alert, and communicate in real time.

4/23/2019 12

TapCloud Application

Two sides to TapCloud:

• Patient-facing app works on any

smartphone or tablet

• Patient-reported Information
• Medication and Appt Reminders
• Data tracker
• Private, secure communication link
• Provider dashboard for patient

monitoring and alert system

Patient Platform Provider Dashboard

4/23/2019 13

4/23/2019 14

SMART Pilot Study

Smart Phone Application to Improve Renal Transplants

• Investigator-initiated prospective pilot clinical trial of

prevalent 18-34 year-old kidney transplant recipients in the UW Transplant Program

• Goals: Assess the feasibility and efficacy of the

TapCloud application over 3 months, compared with standard of care, at improving Quality of Life

SMART Pilot Study

Smart Phone Application to Improve Renal Transplants

• SPECIFIC AIM 1:

To examine the feasibility of a mobile interactive health care platform, TapCloud, measured by participant enrollment and usage frequency by young adult kidney transplant recipients over 3 month follow-up.

SMART Pilot Study

Smart Phone Application to Improve Renal Transplants

• SPECIFIC AIM 2:

To assess patient and provider experience with TapCloud platform measured by clinically-relevant

• utcomes and qualitative surveys in young adult

KTRs and their transplant providers over 3 month follow-up.

4/23/2019 15

SMART Pilot Study

Smart Phone Application to Improve Renal Transplants

• SPECIFIC AIM 3:

To characterize the impact of a mobile interactive health care platform, TapCloud, on Quality of Life (QoL) and self-efficacy in young adult kidney transplant recipients (KTRs).

Kidney Transplant Questionnaire-25

• KTQ-25 developed by kidney transplant recipients

and clinical experts.

• 25 items - classified in 5 domains:
• Physical symptoms
• Fatigue
• Uncertainty/fear
• Appearance
• Emotions
• Responses on a 7-point Likert scale.
• Lowest score represents the lowest quality of life.
• For the analysis, all scores in each domain are

added and divided by number of items in that dimension.

Laupacis et al., Nephron 1993

Inclusion and Exclusion Criteria

Inclusion Criteria Age 18 – 34 years Kidney Transplant Recipient eGFR >20ml/min/1.73m2 Exclusion Criteria Lack of continuous access and ability to use a smart phone Lack of continuous access to ability to use internet Not taking calcineurin inhibitor (e.g. tacrolimus, cyclosporine) Currently on acute or chronic dialysis

4/23/2019 16

Schedule of Events

UW Transplant Clinic Patients Screening & Consent (may be part of Baseline Visit)  Eligibility review  Contact and Consent Baseline Study Visit  Demographics  Transplant History  Social History  Physical Exam  Vitals  Height & Weight  eGFR & creatinine  CNI through levels (if available)  Comorbitities  Smart Phone check  Internet access check  KTQ-25  TapCloud App check End of Study Visit (3 Months, +/- 5 days)  Demographics  Social History  Physical Exam  Vitals  Height & Weight  eGFR & creatinine  CNI trough levels (if available)  Comorbidities  ED & Urgent Care Visits  Hospitalizations  Smart Phone check  Internet access check  KTQ-25  TapCloud Usability Survey (Patients and Providers)  TapCloud App check

SMART Pilot Study

Table 1. Characteristics of participants at start of study Total N 22 Age 29 (4) Male 12 (55) Race/Ethnicity Non-Hispanic White 11 (50) Non-Hispanic Black 2 (9) Hispanic 4 (18) Other 5 (23) Education High school diploma or equivalent 12 (55) 2-yr assocaite degree 2 (9) 4-yr college degree 2 (9) Masters degree 2 (9) Professional degree 2 (9) Not available 2 (9) Diabetes type 1 2 (9) type 2 3 (14) HTN 18 (82) SBP 130 (12) DBP 84 (12) CAD 0 (0) PKD 1 (5%) GN 1 (5) Lupus 1 (5) Hyperlipidemia 4 (18) eGFR 50 (13) BMI 28.4 (6.2) Weight (kg) 80 (21) Height (cm) 167 (15) Heart rate (BPM) 88 (12) Temperature 36.7 (0.4) Medication Use Tacrolimus 19 (86) Sirolimus 3 (14) Cyclosporine 1 (5) Mycophenolate Mofetil 9 (41) Mycophenolic Acid 9 (41) Azathioprine 2 (9) Prednisone 20 (91) Cholecalciferol 10 (46) Calcium Carbonate 2 (9) Tacrolimus Trough Level (of the 19 on tacrolimus) 6.3 (2.2) Sirolimus Trough Level (of the 3 on sirolimus) 9.2 (3.1) Number of tranplants 1 17 (77) 2 4 (18) 3 1 (5) Time between screening & transplant 3.1 [ 0.9, 8.2] ≤ 1 yr 7 (32) > 1yr 15 (68) Type of donor living 7 (32) deceased 15 (68)

SMART Pilot Study

Smart Phone Application to Improve Renal Transplants

• SPECIFIC AIM 1:

To examine the feasibility of a mobile interactive health care platform, TapCloud, measured by participant enrollment and usage frequency by young adult kidney transplant recipients over 3 month follow-up.

Table 2. Association of TapCloud use with transplants, age and education Tap Cloud Checkins N (%) TapCloud Checkins, median [IQR] ≤ 15 > 15 Transplant (from screening date) ≤ 1 yr 3 (27%) 4 (40%) 7 (33) 26 [5, 52] > 1yr 8 (73%) 6 (60%) 14 (67) 9 [1, 34] Age ≤ 29 5 (46%) 5 (50%) 10 (48) 21 [1, 34] > 29 6 (55%) 5 (50%) 11 (52) 8 [1, 52] Education High school diploma or equivalent 6 (55%) 6 (67%) 12 (60) 24 [4, 59] > High school diploma or equivalent 5 (46%) 3 (33%) 8 (40) 2 [0, 31]

4/23/2019 17

SMART Pilot Study

• SPECIFIC AIM 2:

To assess patient and provider experience with TapCloud platform measured by clinically-relevant outcomes and qualitative surveys in young adult KTRs and their transplant providers over 3 month follow-up.

Used Tapcloud no yes Provider 6 1 Provder comments Overall: unsatisfied Not User-friendly Very Cumbersome Ineffective Not useful for our patient population; it does not sync with our current patient/provider communication system.

Providers:

• Nurses (4)
• Transplant nephrologists (3)

SMART Pilot Study

• SPECIFIC AIM 3:

To characterize the impact of a mobile interactive health care platform, TapCloud, on Quality of Life (QoL) and self-efficacy in young adult kidney transplant recipients (KTRs).

Table 3. Association of TapCloud Checkins with KTQ-25 Baseline Follow-up Tap Cloud Checkins Tap Cloud Checkins ≤ 15 > 15 ≤ 15 > 15 Physical Symptoms ≤ 2.7 5 (46%) 7 (70%) 3 (33%) 2 (29%) > 2.7 6 (55%) 3 (30%) 6 (67%) 5 (71%) Fatigue ≤ 6.0 4 (36%) 8 (80%) 3 (33%) 4 (57%) >6.0 7 (64%) 2 (20%) 6 (67%) 3 (43%) Incertainty/Fear ≤ 5.0 4 (36%) 7 (70%) 4 (44) 5 (71) > 5.0 7 (64%) 3 (30%) 5 (56%) 2 (29) Appearance ≤ 6.5 7 (64%) 5 (63%) 5 (56%) 4 (57%) > 6.5 4 (36%) 3 (38%) 4 (44%) 3 (43%) Emotional ≤ 5.5 4 (36%) 7 (70%) 4 (44%) 4 (57%) > 5.5 7 (64%) 3 (30%) 5 (56%) 3 (43%)

SMART Pilot Study

Table 4. Association of time from transplant with KTQ-25 Baseline Follow-up Time from Transplant Time from Transplant ≤ 1 yr > 1yr ≤ 1 yr > 1yr Physical Symptoms ≤ 2.7 4 (57%) 8 (57%) 2 (33%) 3 (30%) > 2.7 3 (43%) 6 (43%) 4 (67%) 7 (70%) Fatigue ≤ 6.0 4 (57%) 8 (57%) 2 (33%) 5 (50%) >6.0 3 (43%) 6 (43%) 4 (67%) 5 (50%) Incertainty/Fear ≤ 5.0 3 (43%) 8 (57%) 3 (50%) 6 (60%) > 5.0 4 (57%) 6 (43%) 3 (50%) 4 (40%) Appearance ≤ 6.5 4 (67%) 8 (62%) 4 (67%) 5 (50%) > 6.5 2 (33%) 5 (39%) 2 (33%) 5 (50%) Emotional ≤ 5.5 4 (57%) 7 (50%) 3 (50%) 5 (50%) > 5.5 3 (43%) 7 (50%) 3 (50%) 5 (50%)

4/23/2019 18

SMART Pilot Study Smart Phone Application to Improve Renal Transplants Interpretation

• Representative of patient population
• Most used in
• Early post-transplant recipients (<1 yr)
• Younger KTRs (<29 yrs)
• Less educated KTRs

Pilot trial

• provided valuable feasibility and patient-oriented
• utcome data
• may lead to a multi-center trial

Summary

• Patients are wanting and taking an increasing role

in their healthcare

• Providers need to continue to adapt and include

patients in their healthcare where appropriate

• Health IT may help to safely empower patients to

better care for themselves as youth and young adults

Questions or Comments?

• Jonathan Himmelfarb
• Nisha Bansal
• Ronit Katz
• Karina Klepach
• UWMC Transplant Team