1. Using iPhones to keep Newly Independent Teenagers on their Medications By Max Zamkow habits.stanford.edu

2. The Four Questions Is Medication Adherence really a problem? Why Target Teenagers? Why Target Newly Independent Teenagers? Why use the iPhone?

3. Is Medication Adherence really a problem?

4. A PubMed search for: “Medication Adherence”returned 5959 articles

5. Low adherence with prescribed treatments is very common. Typical adherence rates for prescribed medications are about 50% with a range from 0% to over 100% - Sackett 1979 Even among groups of people thought to be most responsible (Company Executives, Healthcare professionals, etc.), good medication adherence is barely above 50% - Burton 2010 “ Poor adherence to medication regimens accounts for substantial worsening of disease, death, and increased health care costs in the United States.Of all medication-related hospital admissions in the United States, 33 to 69 percent are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.” – Osterberg 2005

6. It’s a Win-Win situation The Healthcare industry (Insurers, Hospitals, etc) saves money Patients have better health outcomes (and less hospitalizations)

7. Why Target Teenagers?

8. You Can’t Teach an Old Dog New Tricks Actually you can, but it’s much more effective to teach a Young one

9. Adolescence, especially late adolescence, is associated with low medication adherence One study looking at transplant recipients found that the rate of medication non-adherence among adolescent recipients is approximately 4 times higher than that among adult recipients – Fredericks Why?

10. Teenage years are associated with…

11. Independence Less Supervision Less Guidance Multiple Studies have shown a significant correlation between increased independence and decreased adherence in adolescents – Sawyer, Fredericks, Kovacs

12. Rebellion Concerns about poor adherence in adolescents often result in protective parent behaviors, such as constant reminders to take their medication. While parents hope the reminders will promote better adherence, their prompts are often interpreted by young people as unwarranted “nagging”, which often if not always has the opposite effect.

13. Why Target Newly Independent Teenagers?

14. “Medication adherence was significantly poorer in the newly transitioned cohort in comparison with pediatric and adult cohorts” - Fredericks “Ages 17 – 19 are associated with themost amount of time being noncompliant” – Kovacs “Poorer adherence [in adolescents] was significantly related to older age” - Fredericks Newly Independent Teenagers have the worst medication adherence rates

15. “The developmental characteristics associated with adolescence, including the development of autonomy from family, assimilation with peers, separation from parents, and poorly developed abstract thinking and understanding of long-term consequences of present actions, are often difficult to balance with the behaviors required for optimal medication adherence.” - Fredericks Prepare all you can, eventually they all do it… Habit interventions gain power when they are applied during naturally occurring periods of change in [peoples’] lives- Verplanken 2006

16. Improving Medication Adherence

17. First we must discover WHY adherence is low

18. In addition to the teenager specific reasons… Common reasons patients give include: Adverse Effects “Don’t Need It” Too Expensive Forgetfulness Poor / Confusing Instructions

19. Examples of Interventions that attempt to address 1 or more of these include…

20. Information Campaigns Several studies showed that “telling people about adverse effects of their medications did not affect their use of the medications.” - Haynes “Information campaigns that successfully convey information do not necessarily change consumers’ behaviors.” – Verplanken The problem with these campaigns is the Disconnection between changing minds and changing behavior

21. SMS-based Interventions Modest improvement in adherence Addresses “Forgetfulness” Limited to Simple Reminders

22. Patient compliance with antihypertensive medications has previously been boosted by using battery-powered radiofrequency identification (RFID) tags embedded in the lids of pill bottles or in medication blister packs. These RFID tags record each time the bottle is opened or a pill is popped from the blister pack. Now, pharmaceutical companies are pushing the boundaries further by producing ‘robo-pills’ containing tiny microchips. The microchips send a text message to patients’ phones if they fail to take their medication and are said to increase compliance by 30–80% - Roberts Newer Approaches Pill ‘n’ chips tackles non-compliance

23. In fact, many different interventions have been attempted More instruction for patients, e.g. verbal, written, or visual material Counseling about the patients’ target disease, the importance of therapy and compliance with therapy, the possible side-effects, patient empowerment, couple-focused therapy to increase social support Automated telephone, computer-assisted patient monitoring and counseling Manual telephone follow-up Family intervention Various ways to increase the convenience of care, e.g. provision at the worksite or at home Involving patients more in their care through self-monitoring of their blood pressure Reminders, e.g. programmed devices and tailoring the regimen to daily habits Special ’reminder’ pill packaging Dose-dispensing units of medication and medication charts Appointment and prescription refill reminders Reinforcement or rewards for both improved adherence and treatment response, e.g. reduced frequency of visits and partial payment for blood pressure monitoring equipment Different medication formulations, such as tablet versus syrup Crisis intervention conducted when necessary, e.g. for attempted suicide, aggressive and destructive behavior Direct observation of treatments (DOTS) by health workers or family members Lay health mentoring Augmented pharmacy services Psychological therapy, e.g. cognitive behavior therapy, multisystemic therapy Mailed communications Group meetings

24. …yet we continue to search for a better solution

25. Why iPhone?

26. For long-term treatments, no simple intervention, and only some complex ones, led to improvements in health outcomes. They included combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy, psychological therapy, mailed communications, crisis intervention, manual telephone follow-up, and other forms of additional supervision or attention. – Haynes The solution is complex…

27. The iPhone can do many of these things and more… Social (Facebook / Twitter / Other integration) Reminders (Notifications) Communicate with other devices (Bluetooth, Wi-Fi) Information (Internet) And much more…

28. It’s with them CONSTANTLY

29. Keys to Success For an iPhone App to improve Medication Adherence

30. BJ Fogg’s Behavior Model

31. Trigger Make the iPhone DO SOMETHING at the right time Send push / local notifications Add calendar events with alarms SMS MMS CALL (Email)

32. Motivate Make the patient WANT to take their medication Utilize Game Mechanics Imagine piloting a nanobot through the bodies of fictional cancer patients, destroying cancer cells in your path, battling bacterial infections, and managing side effects. This is the Re-Mission game, developed for adolescents and young people with cancer, thathopelab.orgbelieve will help them develop a positive attitude, learn about their cancer and has been shown to improve adherence. – Roberts Competition Social

33. Ability Cheap / FREE SIMPLE Quick and easy to set up Automate whatever possible Consistency

34. In Conclusion…

35. Medication Adherence is a problem Teenagers leaving home are especially at risk They’re also at a point where interventions are most effective A complex solution is needed The iPhone has the capabilities to meet most of these needs and be successful

36. Thanks!