8 1 2012 rapid presentation 4 extendingmedicacare

7/29/2019 8 1 2012 Rapid Presentation 4 ExtendingMedicaCare

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RAPID PRESENTATION 4:

Ext end ing Medical Care

Amy Bauer, MD, Universit y of Wa

shington

Oct av Chipara, PhD, Universit y of Iowa

Mathew Gregoski, PhD, Medical University of South Carolina Ivor Horn, MD, Childr ens Nat ional Medical Center

Maura Iversen, PhD, Northeastern University

Aoife ODonovan, PhD, University of California-San Francisco

Rachel Pat zer, PhD, Emory Univer sit y of School of Medicine

Katherine Schilling, PhD, Indiana University


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Amy M. Bauer, MD MSUniversity of WashingtonAugust 1, 2012


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Katon (2003) Biol Psychiatry.

Ear ly Chr on icDisease

- Diabetes

-CAD

I m p a i r e dSelf-

m a n a g e m e n t-Smoking cessation

- Weight control

- Exercise

Depression

Neuroendocr ine

Dysregu la t ion- Autonomic effects

- HPA Axis

Heal th RiskBehav io rs

-Smoking

- Poor diet

-Sedentary Lifestyle

- Substance Abuse

Depress ion and chr on ic d iseases hav e

adverse b id i r ect iona l assoc ia t i on s

Di

seaseOutcomes

- Diabetic Complications

- Poor Functioning

- Mortality


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Health literacy The degree to which individuals have the capacity to obtain, process, andunderstand 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 whichadversely 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/ethnicdisparities in depression and diabetes care

Nielsen

-Bohlman et al. (2004) Health Literacy: A Prescription to End Confusion.

Kutner et al. The health literacy of Americas adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education. National Center forEducation Statistics; 2006.

Berkman et al. Ann Intern Med. 2011;155:97-107.

Sarkar et al. J Gen Intern Med. 2010;25:962-8.


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Care

ManagerPatientFamily

PCP

ConsultingPsychiatrist

Specializedservices *

* Includes addictiontreatment, social andvocational services, etc

OtherSpecialists

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

This model has been extended to care for comorbid depression and chronic diseases

Untzer et al. JAMA. 2002;288(22):2836-45.

Katon et al. N Engl J Med. 2010;363(27):2611-2620


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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.


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Mobile features + Behavior change principles

Extend access: After-hours,portable, just-in-time

Ease of use: Touchscreen, videoand voice, speech recognition,

language translation Peripheral brain: Prompts,

facilitate contact with providers, pillidentification

Self-monitoring: Mood, activities,behaviors

Enhancing motivation and

engagement

Personalized education

Behavioral scheduling

Goal-setting and problem-solving

Rewards


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Simplifying the Development

of mHealth Systems

Octav ChiparaUniversity of Iowa


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10

Patients 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 ofAlzheimers disease

evaluate the efficacy/impact of medical treatment

e.g., impact of drugs on the patients quality of life

e.g., track impact of cognitive behavior therapy on depression


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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 ourunderstanding

We need better measurement tools!


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Data collection

Feature extraction

Data upload

Big data

mHealth Systems

A typical mHealth system

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


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CSense Toolkit

A macro-programming approach

develop mHealth systems using a singleprogramming 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 concurrencyissues


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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


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se o an m ea e vereBreathing Awareness Training

Intervention for Blood PressureReduction Among AfricanAmericans

Mathew Gregoski PhD: Technology ApplicationCenter for Healthful Lifestyles, College of Nursing.Medical University of South [email protected]://tachl.musc.edu


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Background

For some individuals stress increases heart rate andblood pressure in a way that is detrimental to health

The response is especially disproportionate amongAfrican Americans who experience higher prevalenceand earlier onset of CVD/CHD compared with otherethnic groups.

Researchers have shown breathing meditation/stress

reduction can lower heart rate (HR) and improveambulatory blood pressure(BP) control among AfricanAmericans helping to prevent CVD and CHD;however there is substancial variability across

studies.


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Rainforth et al. (2007) Meta-analysis 17 trials with 23tx comparisons stated among available stressreduction approaches, TM is associated with

significant reductions in BP, other treatments were notsignificant.

Even among "well-designed" TM trials conducted by thesame investigator substancial variability was shown (-

8.5mmHg for SBP).


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Does breathing awareness training work acrossdisproportionate groups and have we examined factorsto explainsome disproportionate variability for BP

control?

Have we previously examined this variability in ourown work?

Environmental backgrounds...YES!Genetic factors affecting physiologicalresponses...YES!

Psychosocial characteristics...YES!

GeneXEnvironmentXPsychosocial interactions...YES!Equal dispersion of real-world variability...YES!

Equipoise among trials....Limited but YES!

Equal TrueAdherence?.....NO! :-(


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Adherence that is objectively measured and yes it does.

As demonstrated by Wahbeh et al (2011) using the ipodiMINDr for meditation, participants subjectively overestimateadherence (85% vs 73%); even when they know it is also

being objectively measured.

What is "True Adherence" and does it matter?


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Three prehypertensive middle school teachers (ages 26, 34, 49)completed 10-minute Tension Tamer sessions 2x day for 3-months with SMS feedback.

Completed 24-hour BP evaluations at the end of months 1, 2, &

3.


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Generating Innovative Solutions to Reduce Child HealthDisparities

NIH mHealth Summer Institute

Boston, Massachusetts

Ivor Horn, MD, MPH

Associate Professor of PediatricsAugust 2012


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The Problem Health Communication and Child Health Disparities

Major Challenges

Child health disparities continue to exist inmany areas

Research to significantly reduce thesedisparities have shown slow progress

Effective health communication has beenshown to improve patient satisfaction and

adherence to treatment recommendations

Previous health communication researchhas focused on provider behavior

Improvements in provider behavior haveplateaued, shifting focus to patient behaviorchange

Health technologies have the potential toimpact behavior change

Innovations have primarily benefitedadvantaged populations, resulting instagnate or widening disparities

Input from disadvantaged populations andthe health care providers who treat them islacking in innovative health technologydevelopment


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Health Communication A New Model

HealthcareProvider

Parent/Guardian Child

Diagnosis/Guidance

History/Needs

Takes Action ImprovedOutcomes

Medical Visit/Follow Up

TraditionalM

odel

Parent/Guardian/

Child

HealthcareProvider

Family

Friends

Other Voices

(Television, Radio,Internet)

Medical Visit

Ex: Church Computer/Phone

Ex: Beauty Salon/Barber Shop

New Challenge: Finding the right mix ofmessage and medium to impact change

NewModel


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Changes in Technology and Usage Patterns Have Created New Opportunities

TrustedContent

InternetSites

SocialNetworking

MobileTechnology

Advances in new technology will not replacethe traditional health care communication

methods BUT can enhance its effectiveness


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


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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

A Role for mHealth in Health Communication

Parent Empowerment Program in

Asthma Care (PEPAC)

Text2Breathe


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Technology Applications forRehabilitation and Wellness

Dr Maura IversenProfessor and Chair, Department of Physical Therapy, Northeastern University

Behavioral Scientist and Epidemiologist, Brigham & Womens Hospital, HarvardMedical School USA

Migration from Clinical


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Migration from ClinicalIntervention to Maintenance

OPTIMA: Osteoporosis TelephonicIntervention to Improve Medication

Adherence

Large Cluster RCT

2089 Medicare beneficiaries with OP

1-year telephone-based counseling usingmotivational interviewing vs intermittent mailededucation

Solomon DH, Iversen MD et al

NIH AR P60 AR 047782


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OPTIMA

7 health educators documented calls in computerdatabase, 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


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Physical Activity in Rheumatoid ArthritisTowards Personalized Counseling

Monitor physical activity usingaccelerometers

Compare to valid & reliable

self-report measuresCombine with biomarkers of

disease activity to assess

impact of PA on diseaseactivity

Iversen MD - NIH # AR057133-01A2

Biosensor based Video Game


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Biosensor-based Video Gamefor 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


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Biosensor-based Game forPersons with Disabilities

Combines eye tracking device anddata glove technology

Personalized clients ROM required, signals

are processed by data collection softwarebefore they are used as game controls.

Any any small but intentional finger flexion triggersflexion sensor - same with thumb sensor

Wrist sensor placement requires 20 degree ROM

VI DEO LI NK TO GAME UTUBE


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RESOLVING PSYCHOLOGICAL STRESS (REPs):

A mobile application to prevent against accelerated

biological aging in individuals exposed to psychological stress

Aoife ODonovan, PhD

Society in Science Branco Weiss Fellow

University of California, San Francisco

San Francisco VA Medical Center


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PSYCHOLOGICAL STRESS RISK FOR DISEASES OF AGING

Matthews et al. (2002, Arch Intern Med) Keinan-Boker et al. (2009, J Nat Cancer Inst)

N = 12,336; 9 years follow up N = 315,544

CHRONIC STRESS & MORTALITY TRAUMA & CANCER


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ACCELERATED CELLULAR AGING AS A MECHANISM OF

STRESS-RELATED INCREASED RISK FOR DISEASE

ODonovan et al. (2009, Brain Behav Immun; 2011, Biol Psychiatry)


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THREAT SENSITIVITY & CELLULAR AGING

Chronic & Traumatic

Psychological Stress

Exaggerated

Threat Sensitivity

Accelerated

Cellular Aging Laboratory-based self-report threat measure

ODonovan et al. (2012, Brain Behav Immun)


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CURRENT TREATMENT OPTIONS:MEDICATIONS & PSYCHOTHERAPY

NOTCOSTLY

SCALABLE

SIDE LOCATION

EFFECTS DEPENDENT


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An mHEALTH SOLUTION?

COGNITIVE TESTING & COGNITIVE TRAINING

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

Information Processing Interventions


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Rachel E. Patzer, PhD, MPH 1,2

Assistant Professor1 Department of Surgery, Division of Transplantation

2 Rollins School of Public Health, Department of

Epidemiology

Emory University

Atlanta, GA


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The Problem Health disparities in access to optimal treatments, such as kidney

transplantation Long-standing knowledge that because African Americans have alonger life expectancy on dialysis compared to whites, that dialysis isbetter than transplant (its not)

Fewer minorities have access to pre-ESRD nephrology care and areinformed of transplant as a treatment option

84 97

277

374

283

122

297

727

0

100

200300

400

500

600

700

800

ESRD Startto Referral

Referral toEvaluation

EvaluationStart to

Completion

Waitlistingto

Transplant

MedianDa

ystoComplete

*p


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Current Paradigm

Lack of information about treatment options for patientsend stage renal disease

Critically important treatment decisions are often madewithout evidence-based information about a patientsprognosis.

Patients most at risk for poor outcomes have the greatestdifficulty in accessing health information.

Previous research suggests that more interactive patienteducation may improve access to transplant, particularlyamong minorities and those with lower SES.

Historically, few interventions to reduce disparities andcurrently no guidelines for patient education for kidneydisease patients.

h i d dd


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What I am trying to do to address

these barriers & how mHealth helpsClinical and Translational Framework for ResearchPredictive Model Development Refine Patient Education Translate to a

ROC Curve iPad Application Clinical Setting

Aim 1 Aim 2 Aim 3

1-Specificity

Sensitivit

y


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Targeted Intervention to Increase Referral

among African American patients

Translate risk prediction model into an electronic, tablet-based instrument to communicate risks of mortality to

patients and providers


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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- andpost 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

ESRD Referral Evaluation Waitlisting Transplant


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Katherine SchillingAcademic AffiliationsIndiana University (Indianapolis)

School of Library and Information Science

School of Informatics

School of Nursing

Research AffiliationsIndiana University Simon Cancer Center

Walther Cancer Institute

Regenstrief Institute


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Problem Statement

Can cancer patient and caregiver symptommonitoring and support interventions impacton:

1) Cancer patients and caregivers wellbeing,self-efficacy, quality-of-life (QOL)?

2) Patients and caregivers health decisionmaking for treatment-related symptommanagement (patients) and self-care(caregivers)?


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Background / Overview

Consumer health, patient self-management Behavioral oncology

Symptom monitoring and managementinterventionso Push filtered, hand-picked, evidence-based

information

Cancer patients

Caregivers

Provide symptom support; promote QOL, healthand wellness

The Caregiver Tool:


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The Caregiver Tool:

Background and History

44 million caregivers in the U.S.

Caregivers at risk for significant and chronic

health problems:

o Increased morbidity

o High levels of burden, anxiety, depression

Caregiver fatigue widely recognized

o Underserved: Caregivers are not the patient

< 15% of caregivers receive professional

assistance coping with their own health,

emotional, social needs


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Solutions

mHealth Goal:

o Translate web-based cancer patient and

caregiver symptom management andmonitoring tools to mobile delivery for

iPhone, iPad, Android, others

S l ti


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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 improvedhealth, wellness, and QOL?


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8 1 2012 rapid presentation 4 extendingmedicacare

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