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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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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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