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Mobile Health Technology: Catalyst for Healthcare Transformation Essential Hypertension as an Example. Subtitle Presenters Date. Frank Treiber , PhD South Carolina Smart State Endowed Research Chair Director of Technology Applications Center for Healthful Lifestyles(TACHL)

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slide1

Mobile Health Technology: Catalyst for Healthcare TransformationEssential Hypertension as an Example

  • Subtitle
  • Presenters
  • Date

Frank Treiber, PhD

South Carolina Smart State Endowed Research Chair

Director of Technology Applications Center for Healthful Lifestyles(TACHL)

Professor of Nursing & Psychiatry

Presented to : Verizon Foundation Conference , 4/2/2012.

,

http://sctr.musc.edu

843-792-8300

slide2

Rationale for three interrelated community based projects

  • Essential hypertension (EH) impacts 33% of US adults
  • EH is a significant  risk factor for CVD, heart attack, stroke, renal failure 
  • Antihypertensive meds. control EH and decrease CVD events
  • Medication nonadherence  is leading contributor to uncontrolled EH
  • Among EH patients, nonadherence highest among Hispanics and African Americans in underserved areas
  • Practical, sustainable adherence and BP management programs needed

http://sctr.musc.edu

843-792-8300

slide3

Rationale contd.

  • Reviews of clinical trials indicate the following improve medication adherence and BP control:
    • Self monitoring of BP
    • Medication reminder tactics
    • Pharmacist /nurse educational & motivational programs
    • Effects usually deteriorate following cessation of program
    • Comprehensive, acceptable and sustainable patient centered program has not been developed

http://sctr.musc.edu

843-792-8300

slide4

Proof of Concept Study Design and Methods

  • Subjects: 3 adult prehypertensives (SBP > 120 mmHg)
  • Procedures:
  • Received Tension Tamer, asked to practice 10 minute sessions 2x a day for 3-months
  • Measures collected at preintervention 1, 2, and 3 months:
    • -Resting Hemodynamics and 24-Hour Ambulatory BP
    • -Overnight Urine Sample
    • -Awakening response saliva sampling

http://sctr.musc.edu

843-792-8300

slide7

Tension Tamer Heart Rate Acquisition

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843-792-8300

slide8

Tension Tamer Results

http://sctr.musc.edu

843-792-8300

slide9

Proof of Concept Results

  • Reductions in Salivary Alpha-Amylase awaking curve (Marker of SNS activity) from pre to post 3 month intervention.
  • Dose-Response Reductions in 24 hour Ambulatory Blood Pressure. Reductions corresponded with Tension Tamer Adherence rates.

http://sctr.musc.edu

843-792-8300

slide10

Proposed Feasibility Study Design and Methods

  • Subjects: 60 stage 2 preEH adults (SBP 130-139 mmHg)
  • Procedures:
  • Random assignment to Tension Tamer or standard of care 6 months
  • Measures collected at preintervention 1, 3, 6, and 12 months:
    • -Resting Hemodynamics and 24-Hour Ambulatory BP
    • -Overnight Urine Sample
    • -Repeated saliva sampling

http://sctr.musc.edu

843-792-8300

slide11

Rationale contd.

  • mHealthtechnology enables opportunity to integrate these tactics and help:
    • Patients establish self management skills
    • Patients avoid frequent office visits/check ups, etc.  
    • Providers deliver care in more timely manner 
    • Facilitate communication between providers & patients
    • Establish and sustain BP control

http://sctr.musc.edu

843-792-8300

slide12

Preparatory Findings

  • Key Informant Interviews
    • FQHC patients (21 minorities, mean age: 34.5 yrs.)
    • 29% had uncontrolled EH
    • None had taken meds. in 1 yr. (reasons: poor planning; forgetfulness)
    • 95% owned cell phones (20% had smart phones)
    • All highly receptive to using mHealth technology for med. adherence, BP monitoring, linkage to doctor & fewer trips to clinic

http://sctr.musc.edu

843-792-8300

slide13

Preparatory Findings Contd.

  • Mini Proof of Concept Study
    • Purpose: Determine acceptability of the mobile tech. system to patients and providers
    • 4 uncontrolled EH FQHC patients (2 Standard of Care [SOC] , 2 SMASH) for 3 months.

http://sctr.musc.edu

843-792-8300

slide16

mHealth Technology

http://sctr.musc.edu

843-792-8300

slide17

Preparatory Findings Contd.

  • SMASH Results:
    • High levels of patient & provider acceptability;
    • 95-100% med. & BP adherence rates;
    • High desire to continue SMASH;
    • Large, sustained BP reductions;
    • EH became controlled

http://sctr.musc.edu

843-792-8300

slide20

SMASH Time Table

  • Months 1-3: Focus Groups & Key Informant Interviews: Refine SMASH (e.g., motivational /reinforcement messages, educational messages /video clips; feedback reports)
  • Months 4-6: Complete software programming based upon above findings
  • Months 7-12: 3 month SMASH vs. SOC pilot clinical trial (16 EHs from 2 FQHCs)
  • Months 13-15: Statistical analyses, follow-up focus groups for SMASH refinement
  • Months 16-24: 6 month feasibility clinical trial (48 EHs from 6 FQHCs)

http://sctr.musc.edu

843-792-8300

slide21

Months 7-12: SMASH

  • Pilot Trial: Design & Methods
  • Subjects:16 uncontrolled EH, AAs and Hispanics 
  • Procedures:
    • Random assignment by FQHC to MedMinder/BP system vs. SOC for 3 months
    • Smart phones used for signal transfer and patient –provider linkage
    • Provider summary reports bi-monthly; immediate alerts when beyond thresholds
    • Measurements at pre-treatment, 1, 2 and 3 months (resting hemodynamics, 24hr Ambulatory BP)

http://sctr.musc.edu

843-792-8300

slide22

Months 16-24: SMASH

  • Feasibility Trial: Design & Methods
  • Subjects:48 uncontrolled EH, AAs and Hispanics 
  • Procedures:
    • 6 FQHCs (8 uncontrolled EHs per clinic)
    • Random assignment by FQHC to SMASH vs. SOC for 6 months
    • Measurements at pre-treatment, 3 and 6 months

http://sctr.musc.edu

843-792-8300

slide23

Rationale

  • ESRD afflicts more than 500,000 people in the USA
  • HTN and DM are the #1 and #2 causes of ESRD
  • Kidney transplantation is the treatment of choice for ESRD
  • Kidneys are an incredibly scarce resource which mandates that their use be optimized
  • Despite significant advances, average graft survival is suboptimal at approximately 9 years
  • Graft survival is worse among African-Americans and those of lower socioeconomic status

http://sctr.musc.edu

843-792-8300

slide24

Rationale

  • Medication nonadherence is key contributor to premature graft loss
  • Approximately 35% of renal transplant patients are nonadherent and issues often develop within weeks of transplantation
  • Medication nonadherence contributes to graft loss by allowing for immune mediated rejection and the deleterious effects of poorly controlled HTN and DM
  • Mobile health technology has the potential to improve medication adherence, blood pressure and blood sugar control, and graft survival

http://sctr.musc.edu

843-792-8300

slide25

Aim

  • Utilize wireless technology to identify nonadherent patients early after transplant and to interact with them in real time to improve adherent behaviors as a means to improve:
    • Medication adherence
    • Control of HTN
    • Control of DM
    • Graft survival

http://sctr.musc.edu

843-792-8300

slide26

Study Design and Methods

  • Type: Randomized control trial
  • Subjects: 20 nonadherent kidney transplant patients
  • Methods: randomly assigned to:
    • Group A: standard post operative care
    • Group B: “bundled” wireless real time medication reminder system, blood pressure/blood glucose monitoring, cognitive behavior adherence skills enhancement program

http://sctr.musc.edu

843-792-8300

slide27

Study Design and Methods

  • Technology
    • Maya MedMinder to monitor and aid in medication adherence
    • Bluetooth enabled Fora D15b to measure and record BP and blood glucose
    • “Smart” phones for signal transmission
    • “Smart” phones for patient interaction
      • Cognitive behavioral enhancement techniques via video conferencing with adherence coach

http://sctr.musc.edu

843-792-8300

slide28

Study Design and Methods

  • Outcomes (measured pre-, 1, 2, and 3 months):
    • Medication adherence (Maya MedMinder)
    • Blood pressure control (Fora D15b, 24h ambulatory BP)
    • Blood glucose control (Fora D15b, HgbA1c)
    • Immunosuppression (FK506 variability)

http://sctr.musc.edu

843-792-8300

slide29

Rationale

  • Essential hypertension (EH) impacts 33% of US adults, higher prevalence among African Americans (AAs).
  • EH is a significant risk factor for CVD, heart attack, stroke, renal failure.
  • Leading predictor of EH is preEH (SBP/DBP 121-139/81-89 mmHg)
  • Sustainable/easily disseminated prevention programs needed
  • Breathing meditation shown to reduce BP among EH and preEH AA patients
  • Smartphones enable large-scale/easy dissemination

http://sctr.musc.edu

843-792-8300

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