Current State of Medication Adherence: Challenges and Solutions



slow down and our good morning depending on where you are on this beautiful day this is Wendy Nelson from the office of behavioral and Social Sciences Research here at the National Institute of Health welcome to the neck and the adherence research networks distinguished speaker series I am absolutely thrilled today to to introduce our speaker who is Hayden Bosworth who is here from Duke University dr. Barnes Bosworth is a health services researcher who focuses on patient organization level factors to improve treatment adherence he's the associate director of the Center for Health Services Research and primary care and a Career Award scientist at the Durham VA I think you're going to find that this is just going to be an amazing presentation and I know you don't want to hear me so with that I'm going to switch to dr. Boswell from everyone thank you for the opportunity I'm very thrilled to be here I'm going to talk about the current state of medication and the challenges solutions find a way – all right we're having a little key but yeah so just the outline I'll talk a little bit about what the problem is the current policy and the landscape of issues talk briefly about medication here intended we measure it I'll talk a little bit of patient provider communication I'll add a little bit on mountain mobile health in regards to medication hearings and then summarize patient so kind of a whirlwind tour but I'll try to hit some of the high points let's rid of this afternoon so this is not any surprise but the hearings is a huge issue and I would argue is probably one of the largest public health problems that we are experiencing all guests have been muted determine of the effectiveness and in general the rectum prevalence data suggests about 50% of people take the medication as prescribed appropriately this translates into approximately 300 billion dollars in healthcare cost and I would also are including that 300 billion there's patient safety that contributes to that huge number there I also think again in light of the policy issues over mention a little bit there has been significant changes in the use of generics and current legislation changes are going to result in the number of people between the healthcare system and how that will impact medication leave out so it doesn't surprise me anymore that across any disease any problem there is always a here and sis was an article that was first transplanted hand and unfortunately the individual wasn't able to adhere to his drug regimen in the hand despite it successfully working was not able to follow the treatment and they had to remove the hand we see this in transplants and other various things and we'll talk a little bit about these challenges but it's not just the simple chronic disease medications but it's across multiple areas and we see problems there with adherence thank you so some of the problems facing payers if we also put this into context policies CMS has instituted a five store quality system to rate how well pill refill how we're doing with adherence to the healthcare plan and the legislation is changing such that by 2014 a three star medication Advantage plan stands lose an average of 16 dollars per member and which translates into almost $200 a year so where there was currently incentives might've benefit you need color so there will be penalties as we move to in 2014 so there's a lot of challenges in the healthcare environment of how do we improve the adherence rates and I think that's changing the the overall landscape and how we're focusing on that so these motivations are resulting at how do we improve these star ratings how do we increase market opportunities membership these quality bonus payments and then basically how does that result in increase plan profitability so for those of us who've been doing adherence for a while now it's early on it was a little challenging because we didn't get as much attention but with these policy changes that are aligning a much more focus and interest in these topics or becoming more of an opportunity for us to collaborate in that too so it's just quickly the star rating the diabetes the other thing to frame this is is that it's diabetes hypertension cholesterol and I think it's really important to highlight why those three drugs for classifications were chosen part of it is is because those are lower cost medications with a pretty good track record of effectiveness so a lot of the science literature looks at the evaluations are still reasonably inadequate and I think that's an area that we do need to focus more on in the census is that adherence isn't proxy and that even when you have someone adhering it doesn't necessarily correlate with good outcome so this is where we're starting from I think there's rooms for us to improve but if we were looked at for diabetes here the PDC is the possession the proportion of the bay is covered and you can look at the one two three four and five star and so in general if you're at about 71 to 75 percent you're a three star and so the goal is try to move into a four star which is a slight improvement adherence defined by pill resale and then the five-star the point to is as five-star still only at 79% pill refill adherence rates so it's interesting because there's a disconnect in the literature because when we look at total refill we look at it hearings we arbitrarily define as 80% or greater and we were just talking briefly duck Nelson and I and others in the room that may be adequate for certain drugs but definitely would not be adequate for HIV or other medications so again this is I think a way of defining it's where the movement is but it also does take from a health care plan significant changes to go from a 71 to a 70 5.4 percent improvement in adherence so just to summarize I think what the goal of medication in here achieving optimal medication adherence depends on the patient being prescribed the right medication filling it and taking it correctly over time and it requires the appropriate prescribing effective patient provider communication coordination and active engagement participation by the patient there's a lot of pieces there and it's the point to is simply it's just not the patient popping a pill if there's a lot of parts that need to be considered and put into place to ensure that adequate adherence and treatment outcomes are met another way to operationalize this is a quick schematic that I put together that if we defined adherence in the context of medication is a truly complex behavior so the assumption is you have a problem you make or you need to make an appointment you need to accept and believe that there is a need for medication except that medication and then go fill it now right off the bat there we oftentimes the literature look at primaries here non adherence in 20 to 25 percent people don't even fill the prescription so when we're looking at the fill rate and then taking the medication and then pill refill or usually exciting 50 percent but I would argue that this really 50% is assuming you've already filled it and it has a excluded that 25% who may not even think fiction and filled it and then this cycle continues and returning to the provider for the monitoring and then getting another prescription or refilling it now that's typically one drug now we times it by nine or ten drugs you can start seeing the complexity and the challenges that may exist the in terms of just medication adherence again we were briefly talking before we started and talking about some of the factors that we think are relevant to non adherence but if you look across the literature there have been about over a hundred factors at this point that have been identified that have been predictive of non adherence so the challenge for us both in the research environment as well as well as in the implementation environment is how do we create programs that improve adherence but yeah des can target or tailor to despite all these potential factors so how do we create something that's scalable that's cost effective and then also come back to this in a moment but how do you initiate and then maybe create habits and long term maintenance and that that's something really important because for many drugs that's beyond acute we're trying to get people to either take them for long periods of time in the context of cardiovascular drugs or so forth but and then we also could talk about other drugs where we want to decrease the use of it pain medications and so forth I won't talk too much about those types of drugs and talking more on the context generally of chronic long-term medication so this is just a theoretical framework that helps us justify where are we starting what are we looking at and understanding the moving parts there again it's easy to assume that the patient characteristics there's the social cognitive theory where you have to look at the perceived risk and the benefit understanding those cognition forgetfulness is really key aspect that most of us will focus on the other part of cognition is inductive reasoning so if I wake up at 8 o'clock and I have to take the medication three times a day I have to be able to do the calculations in my head that that is eight and then in eight hours later is a four o'clock in the afternoon so being able to do that type of math is important literacy I won't spend too much time on it but yet 25 to 40 percent of our primary care setting that we see at least in our context are functionally illiterate which means that they really have a hard time understanding the back of the tylenol model let alone the handouts that we often give our patients so literacy is a big issue we need to think about I'll come to the coping and stress in just a moment that daily hassles and aggravations really long term have I think huge implications side effects are obviously key aspects some of our own work what we find is that allowing patients expectations of what the side effects are and how to handle them can actually be really helpful to alleviate those issues mental health big aspect there particularly depression one of the most consistent predictors of non adherence or depressed individual and then comorbidities the more complex the it's not the number of drugs it's the complexity that drugs really have an impact on non adherence so those are some of the patient characteristics then there's obviously the provider characteristics which I'll come to in a moment but communication style there's a lot of work that the search is doing in shared decision-making that's really important intensity of therapy there's a lot of work early on in clinical inertia where providers aren't necessarily following guidelines or there's a little bit of slippage understanding the medication regimen I could also call it their care coordination you know when there's multiple providers involved how does that all handle then there's a policy I mentioned briefly the CMS five-star ratings earlier but there's also the medical environment the community and then all this has an impact on treatment adherence and the important point of all this is that oftentimes adherence isn't really a primary outcome it's the proxy and in the end we're trying to really improve outcome but this is just a framework for us to try to figure out what do we think are the major issues if we were to look at all those factors that have been shown to be related to medication adherence you'll also notice that I did not put in a demographics or social at financial aspect those are key aspects but oftentimes those are can't modify someone's race or necessarily educational level so for us we're looking at modifiable factors so so I wanted just briefly one of the things that I recently just published that I think it's kind of exciting and again it's good to have this cross-pollination this this is work that initially was we took from the HIV literature but we just completed a study of post mi patients who were getting a web-based intervention or a nurse based intervention with the web we're still I don't come back to some of the data because I think the using technology is helpful but there are some challenges depending upon populations and I'm sure that data but for this part here I would just want to an aspect that we haven't really tapped into a lot I think of is a chaos and so with us we looked at a post mi patients or about 400 individuals they recruited from three main hospitals and as you look to left that 0.07 is life like chaos so this is a vapid measure but it's addressing questions like I'm always late there's always something going on and something we can miss you're relatively quickly but yet the take-home messages is despite putting all these other factors that we would envision into a model we still find that life chaos is still significantly predictive of outcomes and I think the important part for us is it's a modifiable factor that we could perhaps look at so I think it's an interesting topic that we're further exploring and again coming from the HIV literature so just briefly again we found that 43% despite having a heart attack recently reported that they were non adherent to the cardiovascular medication last month and the independently lace-like chaos was an important factor for non adherence this kind of leads to the issues regarding of medication measures of adherence and just want to highlight these we can use cheap easy to use methods and then there can be more expensive relevant more reliable measures and I think there's a place for all of these the question is is where what's the question we're asking who's using it and what do we need to know well from a clinical perspective if I'm just simply the providers trying to identify whether or not someone's adhering simply asking them in a non-judgmental way are you having any problems with your medication if they say yes a good indicator that there's a problem but you know for more complex drugs or where there's concerns that people may not be taking them we can rely on technology and other various things but again costs are issues I think we have to balance both from the time and the implementation of the devices themselves and I would argue that we're still grappling with measurement of adherence I think the 100 pound gorillas is the pill refill adherence that CMS is using but I think that in general we really are looking at multiple aspects of adherence were measuring it a paper we junior faculty member published that we were involved with was looking at self-important pill refill adherence and the question was are they how related are they are they actually two distinct behaviors so just looking at that if you look at 30 days 50 day or 90 day refill relative to a four item question that asks are you have you been forgetful or you're careless you stop when you feel good you stopped me feel bad the kaepa statistics are pretty poor you know ranging from point one to point one three so here you could say well what am I supposed to do at this point and so the take-home messages is actually both we're predictive of blood pressure so both the pill refill whether under supply or oversupply so oversupply is a kind of would be pill hoarding where you have 120% of greater adherence and then under supply would be less than 80% and then the self-reported were both so all three were indicative poor blood pressure in this study so I think that the take home us is that we argued work they are both important till refill and self-report that they're measuring different aspects of making parents oh excuse me so the other part is you know this is a study that Ryan Shaw who's a junior faculty postdoc did with me where he looked at baseline and 24-month outcome and again you know the self-reported adherence quickly assessed was a pretty good indicator upwards of twenty four months after 24 months there was no longer predictive of blood pressure control and so you know I think we have to continuously assess adherence but you know at the end of the day how frequently do we need to do that and the data suggests perhaps you know on average six to twelve months is a good indicator of poor outcome at least in the context of blood pressure control and lastly I just want to this is an example of a trial that we published earlier and this was a good example of also the transition from effectiveness to implementation and so in this trial among 558 Medicaid patients we gave our general self management program with which did have a significant focus on it medication adherence but also trust issues like alcohol following stofan but I summarize that the adherence rates using medication possession ratios went from 55% nine to twelve months prior to the initiation the program the 77% you know this was a quasi-experimental design and we didn't have randomization but when we looked at the comparison of a four thousand individuals who would have been eligible for the program they stayed consistent at fifty-five percent so just the point is is that in general too once we do our trials could think about who the stakeholders are engaging them in so that we can have these transitions where we can then take our project projects and hopefully successfully implement them into the real world so I want to transition a little bit to where is the role of the clinician and patient and the role of communication so effective that therapy is really involved patient hearings and effective disease management I think patient hearings is one part of the larger self-management issue and I think I often say that takes two to tangle at least so the patient is usually the focal point but a lot relies on how they are interact with the healthcare system particularly the providers or provider or providers and how they work with them so I think the patient-centered medication management is this kind of model that we've been moving towards involves the shared decision-making answering to reach provider patient concordance it doesn't work off and that times when a provider just writes a prescription without engaging the patient seeing where they are their beliefs with medication their thoughts regarding that it also assumes that there's effective prescribing by the provider so are they using evidence-based guidelines are they dealing with clinical inertia and really focusing on watching and doing what's appropriate based upon the current guidelines and then tracking the feedback by the patient self monitoring and then basically the medication taking behavior so there's a cyclical fashion that we really need to think about one of the challenges is again as we move from an effectiveness randomized control trial to implementation intervention looking at the reimbursement and how do we do all this it's it's easier in a research environment but oftentimes there's a disconnect between what we do in the research and how we get that into the real world and again I just keep pointing it out that I think we need to keep that in mind as we do this type of work so provider communication I think is a really powerful tool that can help improve outcomes in both enhancing patient knowledge they addressing their beliefs and often also improving satisfaction with treatment an important thing to keep in mind too is that oftentimes multiple studies have shown that patients only recall about 50% of their information that's provided so we need to think a little bit about how we are conveying this information and currently to the role of mobile health but I think that's a particular area where mobile health can be very effective in helping not only recall that also helped reassure and comprehend information and that this poor patient comprehension recall contributes to some winning or non adherence so some of the collaborative communications provide clear instructions now this means seem pretty obvious but oftentimes we've heard people say well pick the medication twice a day well many of us would assume that well that means I take it at 8:00 and I take it 12 hours later but there are a good proportion of individuals who may interpret it that twice a days I take two bills in the morning and I'm good for the next day so defining very clearly how medication should be taken is one important point I mentioned earlier the side effects and being able to really give the patient some clue of what the expectations are and what to do if you experience these side effects I think that you know really understanding where the patients are do they want a per turn allistic and you know being told what to do or do they really want it involve and shared making there's a lot of complimentary medicine that occurs in that and we don't look at those things which have tremendous possibilities of interactions with the particular medications but I think there's also the data suggest that there's a kind of a misperception unfortunately that providers don't want to open these conversations because they may lead to a 20-minute conversation which with a 15 minute visit is challenging so a lot of the programs that we've heard on are trying to use and do it outside the the actual clinic visit but yet thinking about how reimbursement can be incorporated into that so again just you need to measure correctly consistently in adequate timeframes so the other part of this is is that it's not just adequate to have this initially whether the start of a new dosing or new medication this needs to reoccur frequently to not only ensure that persons doing was but down the road of continuing that they're following through in assessing patients adherence before making changes so there's a great body of work that the group at University of Michigan and Eve per visualize prep done where they looked at clinical inertia and medication adherence and oftentimes that what we see is a poor outcome may not necessarily being patient adherence could be attributed to poor clinical inertia so that's basically providers not being assertive or aggressive enough in treatment or are also getting caught up in other comorbidity issues so some of our own work right now it's looking at pain and hypertension and so oftentimes patient will come in they want to talk about pain but the blood pressure is a little poor and you can imagine that you know which really gets focused on so that again goes back to the patient provider negotiating what's discussed and where things are I mentioned a ready to expected side-effects alternative provider support so not just looking to the positions the alternative case managers social workers and family are key to a lot of this so I just want to briefly also put this in a larger context I think back agent hearings can define as perhaps a complex behavior but I think it ends up being in a larger context of disease management and so when we're implementing these programs what we find is that with that groups don't want to see silos they wanted all-encompassing platform where issues regarding weight diet the medication can be all found simultaneously now that's not necessarily from a research perspective but as we think about moving these into the real world and implementing them we need to think of it in the context of larger context all the other pictures going on and then again envisioning that how do we implement these in non-traditional settings outside of the clinic and how can we do this as easily administered and tailoring to the patient's needs and in the most cost effective ways of doing it and then in the context of disease management looking at multiple behaviors so quickly as we've done this across a number of different diseases and different issues but in general there's a lot of the same underlying context whether it's and diabetes or in sickle cell and part of that is the patient's understanding the risk and the benefit what is the disease why am i taking the medications what are the best the risks of doing this and if I don't do treatment as well as the risk associated with medication I understand the side effects knowing when as I experience something what do I do but again underlying of that that you can see a lot of common framework that can help generalize across multiple behaviors and diseases so I've already alluded to this I want to also highlight I think there's three stages to medication here it's the initiation there's a sustaining and the behavior main and I think it's really important to keep all three in your mind and I think there's a lot more work done in initiation and perhaps sustaining but very little in the maintenance and you know and so in a trial we recently published an archives of internal medicine as a telemedicine project for hypertension and one of the lessons we learned was that there was a huge proportion of individuals who they measured their blood pressure they were doing everything that they needed but we didn't really need to do anything except to send them eventually reminders every six months because they were following the recommendations the blood pressure was in control there wasn't anything for us to do and that was approximately about 40% of the population and so you know what our goal then eventually translated into is maintaining their behavior so we kept sending them positive reinforcements reminding them that where they're still in the project but it was a lesson for us to think about that it wasn't just simply getting the blood pressure under control once they were successful what do we do with those people I also want to highlight I think some of the techniques that are involved with what we're talking about I don't think that there's going to be one particular mode to improve outcomes in the context of adherence I think we need to think of almost a toolbox so our own work has looked at level of motivation the role self-efficacy problem-solving positive and negative framing cueing chaining cueing and chaining particularly keep the example I have to take a particular medication the evening and just once a day and drove me nuts of Here I am doing work in adherence and I'm retired in the day and I forget to take my medication so it wasn't until I realized that I needed to brush my teeth before I got into bed because my wife kicked me out of bed with stinky breath so I put the medication right by the toothbrush so there can be very simple things that we can do as well as get into really complex things so that anyway so just having also setting realistic goals action steps software ward rehearsal cognitive and share decision-making and then one other report I'll cut to at the end is I think behavioral economics or a key growing area that we should think about as well so just in general again focusing on some recommendations regarding maintenance and sustainability long-term sustained adherence is oftentimes only obtained by a small group of patients and we just don't have as much work as I think we that we need to look at to focus on this and it's an area that hopefully will continue growing further and we can look to our social psychology colleagues because what we're really trying to do is create habits so I could see you all I would ask you how many of you brush your teeth today how many of you plan to exercise you know we all get into specific habits and so the goal is is at least with cardiovascular disease medication where there's good efficacy of the drugs want to try to create this that it's just a habit that if you forget to take your medication you realize you feel uncomfortable it's like patting your your wallets or you realizing your keys are missing so that's that's what we're trying to translate to so again here just making that habit scrutinizing ways and it's forming these habits over time so one thing – so in terms of the program's these terms like tailoring and targeting and and I want to put this in the larger context of patient centered care you know you move from the left to the right in terms of complexity and effectiveness I think but you can get into personalized where it's just simply the name of the person single characteristics targeted maybe just so that certain groups older adults younger adults may get relevant information and then we get to individualization and tailoring where we can get not only targeting but identifying perhaps levels of motivation beliefs and when we get more into those levels we generally see it's more effective and we can get to the point now with technology to make those scalable to try to individualize and tailor these programs so just quickly a little bit about tailoring that's collected so that it is dependent upon collecting new data so that you can create and tailor the message it can be on cultural personal beliefs and past behaviors are just an example even you know in terms of under use we can look at why if we're targeting underneath we can look at perhaps contributing factors if the poor communication with doctors mistrust light effects concerns just a couple examples and they depending upon if the problem is poor communication then some of the stuff we've done for example would be perhaps role-playing with the individual how how could they improve that those relationships so if they feel brushed we can work with them and provide some examples of you know entering the room and with a list and saying here the two things that I'd like to be able to address and role-playing mistrust and the doctor or some other issues that we've worked on as well I mentioned the side effects I just briefly again if they overuse you know when we talk a bit adherence we have to be careful not to only focus on utilizing an increasing utilization there are areas particularly for pain medication that we want to decrease the utilization so it changes the the whole definition of adherence upside-down but it gets understand why there's a greater need for perception for the need history of substance abuse poor communication of the doctor and addressing those so often times we depending on what we're focusing on we need to be careful if we're looking at under user overuse in the context of adherence but can tailor these messages to adjust the dishes I also think I want to just highlight step level of care I think that you can almost validate the level of intervention to the Ellis's of what the patient needs I mentioned the example of trial where we had a group that were self-monitoring and they didn't need anything beyond positive reinforcement because they were doing everything that they needed so you know hopefully and we're seeing this is that perhaps creating programs and interventions and studying them we're say 50% get a low intensive program and then they trigger something that's more intensive and that may involve some type of nurse case management or higher level of mobile technology but the goal is that the high touch in-person or pharmacy level which is more cost costly may only be a certain group of individuals and so our analytics and our analyses need to get better and there's good data out there that may be able to allow us to do like that but our goal too is not to wait until the train wreck happens but can we use collective that identified who needs to be triage if you will into the different levels so I think these adaptive designs and trying to create the right tailoring the right dosage of interventions are going to be really key as we move forward smart start transition briefly to mobile health that's probably anybody affiliated dr. Nelson in this group this isn't anything perhaps new but you know I think this is a fast and furious coming down the pike and and we need to be aware of this and how do we incorporate this into care but it's not just simply the cost it's the worldwide use and from an international perspective some of the changes that we're seeing are quite remarkable in countries like Africa areas like Africa and other places where it's almost leapfrogging the web to using the mobile technology and so how do we create programs to utilize those infrastructure and I'll talk a little bit about that but I think at this point right now that in general that you know data is getting better and some of it an early on based on small trials some of its from interest rates so I think that you know the more we push it towards using very good research and methodology will be really key to better understanding what's going on and a goal is to move this toward scientific evidence populations of patients and putting this into the real healthcare system and considering the reimbursement system how do we figure out ways to sustain these programs beyond the research environment so we don't get treated it or thought of the seagulls where we pop in utilize or research infrastructure as the research is done leave that environment I think that we need to be mindful of how do we sustain these and so reimbursement is going to be key so far from my look at them health trials the general shows best outcomes are when delivered with some human support with an opportunity for them to click on options to seek additional if they have any questions or just knowing that there's somebody behind the technology checking to make sure what's going on I think that in general the trials are showing reasonably high attrition rates early on and we're not yet able to see the long term implications but hopefully that will continue be able to look at 6 12 and 18 24 months but right now we're seeing that decreasing engagement over time and how do we engage and keep the sticky to the patient state and individual to use these these programs is a key area that we need to focus more on so I just want to frame you know mobile health Revolt us to have realistic expectations of sort where it is you know I think it's right in the middle between increased rich reach and efficacy so again this goes back to the step level you know that we may need phone counseling programs for certain people that have pretty challenging treatment albert treatment regimens and could be supported with the use of mobile health but not everyone needs phone counseling and individual visits and so the mobile health I think is a great platform that can help mediate those relationships but you know when we're looking at what will help to again from a scalability perspective it's kind of like a public health perspective would we expect to see huge changes in blood pressure for example or a1cs probably not but we have to maybe look at it from a public health perspective particularly if we're trying to frame the cost-effectiveness of the return on investment so again just summarize here so I think it can capture some behavioral and physiological data in real time which is I think really key and it can be utilized to reduce memory issues and capture longitudinal data I think that geospatial technology and date and time stamping are kind of really exciting things that we can utilize so I think you know from a research perspective is creating the environment where we can accept these changes and adapt on the fly if you will but doing it in a rigorous way to ensure fidelity and this is just another schematic of looking at defining how I think mobile health is and so if you look from the left to the right patients prompted to capture data and then these students collected transported to this mobile phone could look at geocoding spam self-report so pain measurements for individuals for the asthma associated with what pollen counts and other things like that so it's trying to really contain advantages or perhaps environmental issues and then processing and and looking at trends and patterns over time and then analyzing and visualizing and feedback so and it's another example that we could use is fit painting blood pressure values trying to remind them to do it periodically and then we've created algorithms that if we get you know three values in a two-week period of time and those are above a certain value we can use those to actually make changes to medication but you know it works in a research environment we also have to at some point work through some of the HIPAA and the FDA regulations on where mobile is and and how we define them this is also some work from our group line shoves part of this dissertation I think this is a understanding the frequency and timing of mobile health and this maybe not need anybody but understanding how do we convey that information what's their perfect dose when do we spend it how frequently so through trial he had done on weight loss that was just published an American general medicine what he found was is that approximately one message per day at 8 a.m. was the most ideal time for most successful for weight loss in and outcome so just presenting that as well but I think we have to be costed technology again back to prior study that I was mentioning before it's called sprite and then to post my patients of about 400 individuals we had about 30% were African American on 28% or reporting inadequate income and that six month with the age these are all individuals who agree to participate in the study they all had heart attacks recently and they all had have accessibility to technology web or computers and despite that 66 percent reported interest in using website to email the doctor 66 would share the health information family members only about a quarter were interested in using the website the same blood pressure or blood pressure blood sugar data to their doctor and 18% were interest in reading or tracking their health conditions I think the data or translates to those who are using the computer more there's better outcomes for their a1c LDL or total cholesterol but as well as blood pressure but I think point two is that some of our older sicker people are where are less likely to be using the mobile technology and so I think what we're looking at is a platform so that it's not just simply a phone app it's interval recognition or other ways and Gary Bennett a colleague of mine has done a nice job of looking at weight loss and in the control the South advocacy of feeling like you can control or decide which mode of administration was very successful in resulting in positive weight loss and so you know at the end of the day for those of us in research we're really hopeful focusing on the content we're the mold that the technology is just part of the tools that we're using the technology is going to continue changing the content and getting it right is is I think the essential aspect of that so in terms of just some recommendations some clinical issues to think about mentioned as before just depends upon what your goals are but if you're quickly trying to assess whether or not some kind of problem this is a question we've used before have you missed any posts in the last week as a reasonable the sensitivity is not great but the specificity is fine so at the end of the day if they say yes they're having a problem can pretty much rest assure that there's something you need to do kind of misperceptions should be anticipated avoided and this may seem like a no-brainer but I used the example of the time my son was 6 years old and answering what the birds and the bees were and for anybody who has kids it's one of the things that you know prepare yourself that you're not necessarily ready for a six year at and six years old to answer that question fortunately my wife is smarter than I am and she said before you answer that question why don't you ask him what he knows already and so when I asked him that he said well I was reading something about Winnie the Pooh and those birds and the bees in it and it was completely off-base of where I was and so you know it's really important to see where the patients are what their thoughts are before we just start the whole rigmarole of giving information so I could have emotionally scarred myself as well as perhaps my six-year-old if I didn't stop and do that so these are some just quick things to consider as we moving forward missing appointment you know someone doesn't show up to have that conversation with you there's no way you can have talked about it here and so particularly if you're looking at a psychiatric round you know you know oftentimes we have titrate the medication it's not that we can just simply prescribe and get it right right out of the back so I think there's some real important key reminders or clues that there's a problem we may need to think about it technology or appointment reminders you know these are inter voice cracking IVR is a quick way of doing this and we can do this technology mobile again 90% of all text messages are opened in 30 minutes or less so I think that's an important thing for us to consider and again the scalability of using that it is pretty can be very powerful so I just want to highlight I think education and knowledge are important that those world by themselves change behavior and so again I use the concrete examples so we people have to have a fundamental level of knowledge to to make informed decisions but that's not going to get us over the finish line we also have to be mindful of the ways and percent information in stretch instructions should be clear and structured and picture charts color coded so some psychologists have done a lot of work and how do we present information I think we really need to take better use of those and then there's also industry where they have done a nice job of doing printouts that represent patients medications and there is additive information that can be provided to the patients if you envision you come in you see the doctor or the pharmacist to get your prescription you get your drug and then you go and then you don't see them for 30 to 90 days we need to be able to have something that's a quick reference to help identify that I think the other thing is you know pill reminders and blister packages those are some other technology that's coming out that I think are could be potentially low-cost ways of helping individuals to remind to take the medication literacy is always an underlying issues that we have to be mindful of I'm going to gain some just behavioral aspects identifying potential relapse into old behavior setting appropriate realistic goals simplifying regiments these you know are very straightforward nothing pilot rocket science here but they can simulate and have large effects and reinforcing positive behaviors I think that sometimes that again goes back to the maintenance issue that we need to not forget people who are doing okay and you know ensure that they continue to do the right thing and then just quickly you know operant conditioning and behavioral economics are important aspects a lot of work now is being done in this area we're whether its incentivizing with financial reimbursement or decreasing co-payments and I think that it's really important work but again I think it falls within the larger context of the multiple things that we need to use to move and improve the appearance so in some right medication adherence is a significant but complex problem and while I focus mainly on the patient a little bit on the provider there are multiple levels from the health care provider and policy need to see the times are changing the policy landscapes incentives for insurance premiums are changing you know data coming out looking at what happens if you actually provide medication for free what is that outcome and those types of things need to continue going forward I think those important improving collaboration around medication hearing so the search movement towards shared decision-making is going to be key in that area and again still not forgetting understanding the mechanisms and contributing factors for medication adherence I feel like in some ways where if you look at healthcare disparities there's really three levels there's the kind of the descriptive studies where I think we've done a good job of showing adherence is poor and you know across diseases and medications we see that there's some variability but you know we have enough to do Cochrane reviews and meta-analyses I think we've done a reasonable job of the understanding some of mechanisms but hopefully if conveyed that I think it's not one mechanism there's likely to be multiple mechanisms depending upon the individual where we really need to focus on is I think trying and examining the interventions parsing at what's working and then how do we implement that into the real world and that that I think is where the new future lies for us and lastly some other things one size doesn't fit all so whether it's step level or creating the toolbox with different methods to improve outcomes for individuals I think we need to continue looking at alternative methods of implementing interventions so peers I didn't really focus on that but in certain communities that can be very helpful and beneficial it doesn't necessarily always have to be a pharmacist I think technology is really going to be key but I worry that if we get caught up in the newest gadgets it may not get us to where we need so I think you know it's not the panacea but it's definitely part of the toolbox we really need to do a better job of costing and looking at these programs and and I think better identifying who the right programs are so that we can better utilize limited in the healthcare system methods for reimbursement so how do we incentivize providers to have who only have 15 minutes to see a patient to engage in medication reconciliation where does that happen who's going to cover that and those are some policy issues that we need to continue I've harped on the initiation and maintaining of adherence I think those are really important and then considering the multi levels already and I think lastly we always need to consider stakeholders so well we can't do everything I want it's really important to identify who the stakeholders are and engaging them not the end but at the very beginning so that we avoid these long drawn-out periods and so I think movements like the quarry are really key the time to engage and learn how to do that with the stakeholders and particularly the patients which is a challenge as well how do we engage patients and stakeholders okay and so and lastly just some of the challenges to separating we from the chapters a lot of work out there some of its on the industry side so how do we really separate the wheat from the chaff and determine what's working with scalability ROI sustainability and ensuring that we're doing a good job of evaluating what we're doing so oh stop first question alright thank you dr. buzzards I think this has been a really interesting and important webinar we do have some questions from the audience and if you have questions so you can do is on Twitter hashtag NIH adherence it should be on the screen or email them to me at il Sen WJ @ OD mi h gov but we have some questions from the audience and both of these are regimen questions so in reference to HIV that you talked about one of our listeners said those regimens simplifications such as 1/2 a day and HIV is helpful for improving it here and says you noted but alternative like a twice a day often improves the outcomes the tolerability the long-term effects while the single pill option receives great MA motion and messaging how do we really communicate to patients which is the best option for them that's a great question and so and I I'm going to now for further feature try to incorporate they incorporate that into any presentation there is always a challenge and perhaps oversimplifying things where we see the data is that when you go to three or four drugs is a huge precipitous drop in adherence there isn't that big of a difference between once a day and twice a day and if you looked at medication for osteoarthritis when when in last month we also have some problems for people forget so there's this optimal level and I would say that twice a day is probably in the ballpark because you're not necessarily having to interrupt your daily schedule to take those medications so and that goes back to the communication so if you're the provider to have that communication say I can provide you an easier medication but the effectiveness is not necessarily going to be as good as twice a day and I think these are some of the challenges or fferent for example the new drugs coming out so the warfarin you know it's been the treatment for 50 years and we have these new drugs that are supposed to be easier once a day and we don't know if that's necessary going to be the right outcome we need to continue looking at so so I think just to summarize I think twice is generally not as problematic as three or four and it also goes back to the patient provider communication and having those discussions great and I we have another question about regimen in terms of factors like color like the color fills the swallow ability of pills the size what do we know about factors the tangible factors in medication adherence do we know any prefer I personally haven't done much work in that but my look at the literature is that work definitely has some challenges with while we've also from diabetes and insulin I mean God just want to any opportunity to avoid having to start insulin is a big issue so that's injection so slightly different so the formulation of the drugs I'm sure and the swallowing is always going to be a problem and I don't have a quick solution for that but again having good communications with a provider oftentimes there are alternatives and maybe there are some solutions or ways of assessing those concerns or problems if those are exists but again it goes back to identifying that that clearly is a problem and figure out a way to resolve that right I have we had a message to it said what about tasting kids and obviously context matters yeah yeah well so you know it's interesting because that's where I think the CVS and the pharmacies you know our local pharmacist farmers will charge ten dollars to put bubblegum flavor in a box of noxus own so anybody's try to get a kid to take the medication you know the challenges of it tastes disgusting and and there's a business model where they actually get you know a little bit of extra money to do that and we've also looked at packaging as well so you know putting put taking your medication putting it in blister packaging and so that you have multiple bugs in those blister packages we don't know what the cost effectiveness is but you know the local retail pharmacies are going to have to figure out what the business model is and maybe those examples where you're kind of almost a specialty pharmacy trying to address the size of the pill the flavor of the pills or that older adults who parents who's on so many drugs having somebody help them and not think that the wife or the parent the child doing the medication total reminders because we also just because we see it consistently that doesn't necessarily mean that they're putting the medications in the right my whole box correctly either so maybe that's wherever all a pharmacist could be okay great and we had one last question I know we were all very interested in your ideas about life chaos but one of our one of our listeners was asking how is it modifiable can you give a concrete example so uh well yeah so I think it's a more modifiable than social demographic factors like race I think that that where we could do it is providing some strategies on how to reduce the chaos so you know looking to our mental health therapists and things along those lines trying to simplify life a little bit I don't mean to be superficial but I think there's a little bit more room to do to address those issues than some of the typical demographic factors so again this comes from the HIV literature and there has been examples where when people are struggling with mental health and all the other issues in getting to appointment scheduling and those challenges helping to facilitate that the role the social workers could be really very beneficial so so I think at a minimum at this point we're looking at a key factor for a risk factor but trying to perhaps circle back with social workers and others but please offline if you have suggestions or other things this is an area that we're just starting to look at that I think will be important well thank you very much I know we all really appreciated that there was dr. Hayden buffer from Duke University and we thank you again from joining the NIH office of behavioral and Social Sciences Research distinguished speaker series in adherence so thank you very much have a great day and we'll talk to you next month

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