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MY SUMR

MY SUMR. Alex Ryu Mentor: Andrea Apter, MD, MSc. Individualized Interventions to improve adherence in asthma. Asthma Brief. Affects 34.1 million Americans, 300M world Inflammation of airway, comes in “attacks” 217,000 ER visits/yr 2007 national cost: $19.7 billion, $15B direct

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MY SUMR

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  1. MY SUMR

  2. Alex Ryu Mentor: Andrea Apter, MD, MSc Individualized Interventions to improve adherence in asthma

  3. Asthma Brief • Affects 34.1 million Americans, 300M world • Inflammation of airway, comes in “attacks” • 217,000 ER visits/yr • 2007 national cost: $19.7 billion, $15B direct • Treated with: • Preventative inhaled corticosteroids (ICS’s) • Emergency inhaler – albuterol • Prednisone – frequently after ER • Lots of side effects, use briefly

  4. The Context • Racial disparity in asthma morbidity exists • Medications are underused by all populations • Even when provided! • Asymptomatic nature of asthma • Ability to self-manage key for adherence • Education alone fails • Want to design an individualized intervention to improve adherence • Monitoring is necessary, but problematic

  5. The Issue of Adherence • Poor adherence can be mistaken for poor efficacy of medication • Leads to a cycle of increasing dosages and complexity without improved health • Monitors for common asthma meds do not exist • Patients might incorrectly recall usage habits • Drug instructions communicated poorly • Methods of measuring drug container ineffective

  6. Make Your Own Monitor • Need monitors for Advair and Flovent – two main prescribed ICS’s – preventative • Flovent exists, need to design one for Advair • Daniel Bogen, MD, PhD • Magnet sensor, basic software • Download at each visit

  7. Advair 100: ~$190/month Advair 250: ~$230/month Advair 500: ~$315/month Flovent 110: ~$160/month Flovent 220:~$180/month

  8. Diskus Adherence Logger (DAL) Bogen, Apter JACI 2004;114:863.

  9. Early Investigation • Focus groups – Influences on adherence • Latino and African American patients • Identified barriers to adherence • Piloted Problem Solving intervention (PS) • Ancillary staff at outpatient visit • Designed to help reduce barriers to adherence

  10. Study Design • RCT, participants receive either Attention Control (AC) or Problem-Solving (PS) intervention • Same length, education previously found ineffective • Meet 8 times, around participants’ schedules • Do spirometry, ask questions, do intervention, download adherence data • Cost-free • Questions regarding other relevant issues • Where get meds, reading ability, depression, etc…

  11. Independent Variables(A few) • Self-Efficacy • Social Support • Depression • Cost of medication • Knowledge of asthma and medication use

  12. Dependent Variables • Adherence • Asthma-Related Quality of Life (QOL) • Asthmatic Control

  13. Specific Aims • Determine whether PS improves adherence over AC • Test whether PS improves pulmonary function over AC • Determine whether PS improves asthma-related QOL over AC

  14. Exploratory Aims • Examine whether patients’ knowledge of and attitude toward ICS mediate PS, adherence • Examine whether social and environmental interactions mediate PS, adherence • Estimate financial impact of intervention

  15. Hypothesis • PS will improve adherence over AC • PS will improve FEV1 over AC • PS will improve asthma-related QOL more than AC

  16. Recruitment • Recruit from UPHS clinics + Episcopal Hospital + VA + Woodland Av – mostly minority • Chart searches • Contact over phone or in person • Screen • Enroll

  17. Eligibility Criteria • ≥ 18 years of age • Currently prescribed a either Advair or Flovent • Pre-bronchodilator FEV1 <80% • Post-bronchodilator FEV1 increase by 12% • No pulmonary htn, or other disease that impairs asthma-related lung measurements • No cognitive or mental impairments

  18. What I did… • Recruitment • Charts – Epic, Mediview • Screening appointments • Compiled participant copay receipts • Administrative tasks • Monitors • Clinical research ≈ PAPER

  19. Status • Finally enrolled 400th participant – unparalleled sample size for this type of study • 5 years in the making • Continuing to follow with visits • Some preliminary analyses, most data still frozen until study complete • Have baseline adherence, questionnaires • Database of copay receipts for later analysis • Dan Polsky PhD, MPP, Sean McElligott

  20. Limitations • Much of secondary data is self-reported • Potential effects of “attention-factor” • Differing reimbursement patterns • Difficulty with scheduling and retention

  21. Lots of Time + Lots of Money=… • Better characterization of impoverished minority patients with moderate/severe asthma • A better understanding of treatment plans to improve ICS adherence • Insights into the numerous social and societal barriers that deter adherence * Ideally, a set of treatment guidelines that will shrink the national financial burden of asthma through improved adherence

  22. Lessons • Recruitment takes patience • Good health is more than not having a cough • Appreciation for complex logistics

  23. A HUGE Thanks to: • Dr. Andrea Apter • Laura Garcia, MPH • Rodalyn Gonzalez and ChantelPriolo • Participants • Joanne Levy, MBA MCP • Shanta Layton • LDI and SUMR • HUP

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