8 1 2012 Rapid Presentation 4 ExtendingMedicaCare | Chronic Kidney Disease | Nephrology

RAPID PRESENTATION 4: Extending Medical Care

• • • • • • • • Amy Bauer, MD, University of Washington Octav Chipara, PhD, University of Iowa Mathew Gregoski, PhD, Medical University of South Carolina Ivor Horn, MD, Children’s National Medical Center Maura Iversen, PhD, Northeastern University Aoife O’Donovan, PhD, University of California-San Francisco Rachel Patzer, PhD, Emory University of School of Medicine Katherine Schilling, PhD, Indiana University

Amy M. Bauer, MD MS University of Washington
August 1, 2012

Depression and chronic diseases have adverse bidirectional associations


Neuroendocrin e Dysregulation
- Autonomic effects - HPA Axis

Early Chronic Disease
- Diabetes -CAD

Disease Outcomes
- Diabetic Complications - Poor Functioning - Mortality

Health Risk Behaviors
-Smoking - Poor diet -Sedentary Lifestyle
Katon (2003) Biol Psychiatry.

Impaired Selfmanagement
-Smoking cessation - Weight control - Exercise

- Substance Abuse

Health literacy The degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate health decisions

Diabetic adults with low health literacy have poorer disease control and adherence to medications for both diabetes and depression Health literacy barriers to self-management may be exacerbated by depression which adversely affects motivation, self-efficacy, and executive function Depression care is complicated by additional barriers (stigma, problems accessing specialty care, etc) Health literacy may be a partial explanation for well-documented racial/ethnic disparities in depression and diabetes care

Nielsen-Bohlman et al. (2004) Health Literacy: A Prescription to End Confusion. Kutner et al. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education. National Center for Education Statistics; 2006. Berkman et al. Ann Intern Med. 2011;155:97-107. Sarkar et al. J Gen Intern Med. 2010;25:962-8.

Outcomes for patients with depression and chronic diseases in primary care are poor; Co-locating mental health professionals in primary care does not improve outcomes

Collaborative depression care:
An evidence-based model that extends traditional care and improves outcomes
Specialized services *
* Includes addiction treatment, social and vocational services, etc



Care Manager

Consulting Psychiatrist


Other Specialists

This model has been extended to care for comorbid depression and chronic diseases
Unützer et al. JAMA. 2002;288(22):2836-45. Katon et al. N Engl J Med. 2010;363(27):2611-2620

Limitations of collaborative care
 Model is intensive in human resources  Services are not reimbursed in many systems  Some patients still cannot be engaged  Telephone outreach requires simultaneous communication

Limited data on use of mobile apps
 Diabetes apps focus on providing general information without

sufficient attention to enhancing motivation

Chomutare et al. J Med Internet Res. 2011;13(3):e65.

Mobile features + Behavior change principles

Extend access: After-hours,

    

portable, just-in-time  Ease of use: Touchscreen, video and voice, speech recognition, language translation  Peripheral brain: Prompts, facilitate contact with providers, pill identification  Self-monitoring: Mood, activities, behaviors

Enhancing motivation and engagement Personalized education Behavioral scheduling Goal-setting and problemsolving Rewards

Simplifying the Development of mHealth Systems
Octav Chipara
University of Iowa

Patient’s behavior and their health
• Patient behavior and their health are inexorably linked • Understanding this relationship will help us
• develop new diagnostic techniques • e.g., assessment of social interactions for diagnosis of depression • e.g., assessment of memory, mood, activity level for diagnosis of Alzheimer’s disease • evaluate the efficacy/impact of medical treatment • e.g., impact of drugs on the patient’s quality of life • e.g., track impact of cognitive behavior therapy on depression


Monitoring patient behavior with manual data collocation
• Manual data collection is the gold standard ...
• subjective (e.g., memory bias, Hawthorne effects) • poor scalability • low temporal resolution • cannot monitor many subjects • people are expensive!

• ... but, our tools fundamentally limit our understanding

We need better measurement tools!

mHealth Systems
• A typical mHealth system

Data collection

Data upload Big data

Feature extraction

• Requires diverse expertise: embedded + web apps + domain experts • Current systems are stovepipe lacking flexibility and reuse • Tedious management of resources on embedded sensors and phones • Developing distributed systems is inherently difficult

CSense Toolkit
• A macro-programming approach
• develop mHealth systems using a single programming abstraction • prototype the development of a system in a centralized fashion

• A data flow language to compose the system
• components - encapsulate the developed code • links - carry data between components • advantages: simplifies resource management, addresses concurrency issues


CSense Toolkit
• Leverage on existing tools - MATLAB integration
• prototyping in MATLAB to allow experimentation • code generation techniques used to deploy MATLAB code on Android devices • only a subset of MATLAB language may be used • integration with MATLAB to deploy code on the server side

• A library of components to rapid development
• existing components may be used to develop significant portions of your app • allows you to focus on the novel aspects of mHealth systems • fosters sharing of components


Use of an mHealth Delivered Breathing Awareness Training Intervention for Blood Pressure Reduction Among African Americans

Mathew Gregoski PhD: Technology Application Center for Healthful Lifestyles, College of Nursing. Medical University of South Carolina gregoski@musc.edu http://tachl.musc.edu

For some individuals stress increases heart rate and blood pressure in a way that is detrimental to health The response is especially disproportionate among African Americans who experience higher prevalence and earlier onset of CVD/CHD compared with other ethnic groups. Researchers have shown breathing meditation/stress reduction can lower heart rate (HR) and improve ambulatory blood pressure(BP) control among African Americans helping to prevent CVD and CHD; however there is substancial variability across studies.

Rainforth et al. (2007) Meta-analysis 17 trials with 23 tx comparisons stated among available stress reduction approaches, TM is associated with significant reductions in BP, other treatments were not significant.

Even among "well-designed" TM trials conducted by the same investigator substancial variability was shown (8.5mmHg for SBP).

Does breathing awareness training work across disproportionate groups and have we examined factors to explain some disproportionate variability for BP control? Have we previously examined this variability in our own work? Environmental backgrounds...YES! Genetic factors affecting physiological responses...YES! Psychosocial characteristics...YES! GeneXEnvironmentXPsychosocial interactions...YES! Equal dispersion of real-world variability...YES! Equipoise among trials....Limited but YES! Equal True Adherence?.....NO! :-(

What is "True Adherence" and does it matter?
Adherence that is objectively measured and yes it does.

As demonstrated by Wahbeh et al (2011) using the ipod iMINDr for meditation, participants subjectively overestimate adherence (85% vs 73%); even when they know it is also being objectively measured.

Three prehypertensive middle school teachers (ages 26, 34, 49) completed 10-minute Tension Tamer sessions 2x day for 3months with SMS feedback. Completed 24-hour BP evaluations at the end of months 1, 2, & 3.

Generating Innovative Solutions to Reduce Child Health Disparities
NIH mHealth Summer Institute Boston, Massachusetts

Ivor Horn, MD, MPH Associate Professor of Pediatrics August 2012

The Problem – Health Communication and Child Health Disparities
Major Challenges • Child health disparities continue to exist in many areas • Research to significantly reduce these disparities have shown slow progress • Effective health communication has been shown to improve patient satisfaction and adherence to treatment recommendations • Previous health communication research has focused on provider behavior • Improvements in provider behavior have plateaued, shifting focus to patient behavior change • Health technologies have the potential to impact behavior change • Innovations have primarily benefited advantaged populations, resulting in stagnate or widening disparities • Input from disadvantaged populations and the health care providers who treat them is lacking in innovative health technology development

Health Communication – A New Model
Medical Visit/Follow Up

Traditional Model


Healthcare Provider

Parent/ Guardian

Takes Action


Improved Outcomes

Healthcare Provider

Ex: Beauty Salon/ Barber Shop New Challenge: Finding the right mix of message and medium to impact change

New Model

Medical Visit

Parent/ Guardian/ Child
Ex: Church Computer/Phone


Other Voices (Television, Radio, Internet)

Changes in Technology and Usage Patterns Have Created New Opportunities
Trusted Content

Internet Sites Social Networking

Mobile Technology

Advances in new technology will not replace the traditional health care communication methods BUT can enhance its effectiveness

Reaching People Where They Are and How They Want to Be Reached

A Role for mHealth in Health Communication Parent Empowerment Program in Asthma Care (PEPAC) Text2Breathe: Getting the
most from any Dr visit is as easy as 3 Ss. Do u remember the 3 Ss? Text Y or N Y=Yes N=No


Technology Applications for Rehabilitation and Wellness
Dr Maura Iversen
Professor and Chair, Department of Physical Therapy, Northeastern University Behavioral Scientist and Epidemiologist, Brigham & Women’s Hospital, Harvard Medical School USA

Migration from Clinical Intervention to Maintenance

Osteoporosis Telephonic Intervention to Improve Medication Adherence  Large Cluster RCT  2089 Medicare beneficiaries with OP
1-year telephone-based counseling using motivational interviewing vs intermittent mailed education
Solomon DH, Iversen MD et al NIH AR P60 AR 047782

• 7 health educators documented calls in computer database, information merged with Medicare claims • Medication adherence reported as median (IQR) medication possession ratio (MPR), 2nd outcomes fractures, falls • 48% possession rate in Rx grp vs 40% in control • No difference in fractures • Customized computer interface easy to use and navigate by Health educators

Physical Activity in Rheumatoid Arthritis Towards Personalized Counseling
 Monitor

physical activity using accelerometers  Compare to valid & reliable self-report measures  Combine with biomarkers of disease activity to assess impact of PA on disease activity
Iversen MD - NIH # AR057133-01A2

Biosensor-based Video Game for Physically Disabled
 Target:

Persons with Rheumatoid arthritis  Problem:
 Pain

and synovitis- wrist/fingers  Poor lever arms  Weak prehension  High prevalence Carpal Tunnel Designers: J Breugelmans, Y Lin, RR Mourant, MD Iversen
Northeastern University

Biosensor-based Game for Persons with Disabilities
 Combines

eye tracking device and data glove technology
 Personalized

– client’s ROM required, signals are processed by data collection software before they are used as game controls.
• Any any small but intentional finger flexion triggers flexion sensor - same with thumb sensor • Wrist sensor placement requires 20 degree ROM


RESOLVING PSYCHOLOGICAL STRESS (REPs): A mobile application to prevent against accelerated biological aging in individuals exposed to psychological stress
Aoife O’Donovan, PhD Society in Science – Branco Weiss Fellow University of California, San Francisco San Francisco VA Medical Center


Matthews et al. (2002, Arch Intern Med) N = 12,336; 9 years follow up

Keinan-Boker et al. (2009, J Nat Cancer Inst) N = 315,544


O’Donovan et al. (2009, Brain Behav Immun; 2011, Biol Psychiatry)

Chronic & Traumatic Psychological Stress

Exaggerated Threat Sensitivity

Accelerated Cellular Aging

Laboratory-based self-report threat measure O’Donovan et al. (2012, Brain Behav Immun)






Information Processing Interventions

Bar-Haim et al. (2011, J Child Psychol Psychiatry Allied Disciplines)

Rachel E. Patzer, PhD, MPH 1,2 Assistant Professor 1 Department of Surgery, Division of Transplantation 2 Rollins School of Public Health, Department of Epidemiology Emory University Atlanta, GA

• Health disparities in access to optimal treatments, such as kidney transplantation
– Long-standing ‘knowledge’ that because African Americans have a longer life expectancy on dialysis compared to whites, that dialysis is better than transplant (it’s not) – Fewer minorities have access to pre-ESRD nephrology care and are informed of transplant as a treatment option
Disparities in Transplant Steps
Median Days to Complete 800 700 600 500 400 300 200 100 0 White Black *p<0.0001 727

The Problem



374 283 97 122 277297


ESRD Start Referral to Evaluation Waitlisting to Referral Evaluation Start to to Completion Transplant

Current Paradigm
• Lack of information about treatment options for patients end stage renal disease • Critically important treatment decisions are often made without evidence-based information about a patient’s prognosis. • Patients most at risk for poor outcomes have the greatest difficulty in accessing health information. • Previous research suggests that more interactive patient education may improve access to transplant, particularly among minorities and those with lower SES. • Historically, few interventions to reduce disparities and currently no guidelines for patient education for kidney disease patients.

What I am trying to do to address these barriers & how mHealth helps
Clinical and Translational Framework for Research
Predictive Model Development
ROC Curve

Refine Patient Education iPad Application

Translate to a Clinical Setting



Aim 1

Aim 2

Aim 3

Targeted Intervention to Increase Referral among African American patients
• Translate risk prediction model into an electronic, tabletbased instrument to communicate risks of mortality to patients and providers

Targeted Intervention to Increase Referral among African American patients
• Recruit ESRD patients (majority AA) from Emory Dialysis (n=60) into a pilot, feasibility study within the first 60-90 days of starting dialysis. • Baseline assessment and measurement of patient preferences for treatment and knowledge of treatment options pre- and post intervention, and measure referral for kidney transplant. • Post-assessment patient satisfaction survey • Goal: to inform a future randomized study of the tool
Step 1 Step 2 Step 3 Step 4






Katherine Schilling
Academic Affiliations
Indiana University (Indianapolis) School of Library and Information Science School of Informatics School of Nursing

Research Affiliations
Indiana University Simon Cancer Center Walther Cancer Institute Regenstrief Institute

Problem Statement
Can cancer patient and caregiver symptom monitoring and support interventions impact on: 1) Cancer patients and caregivers’ wellbeing, self-efficacy, quality-of-life (QOL)? 2) Patients’ and caregivers’ health decision making for treatment-related symptom management (patients) and self-care (caregivers)?

Background / Overview
  

Consumer health, patient self-management Behavioral oncology Symptom monitoring and management interventions

Push filtered, hand-picked, evidence-based information

  

Cancer patients Caregivers Provide symptom support; promote QOL, health and wellness

The Caregiver Tool: Background and History
 

44 million caregivers in the U.S. Caregivers at risk for significant and chronic health problems:
o o

Increased morbidity High levels of burden, anxiety, depression Underserved: Caregivers are not the patient

“Caregiver fatigue” widely recognized

< 15% of caregivers receive professional assistance coping with their own health, emotional, social needs


mHealth Goal: o Translate web-based cancer patient and caregiver symptom management and monitoring tools to mobile delivery for iPhone, iPad, Android, others

Solutions: How can mHealth help?

Issues: o Optimizing convenience and usability  Delivery, design, format, etc. Questions: o How do users interact differently with a mobile app (than they would with a web-based tool)? o In what ways does a mobile platform impact on: 1) Uptake of information? 2) Integration of information for improved health, wellness, and QOL?

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