Tuberculosis - MIT Creates New Testing And Reporting System, Rewarding Patients Who Take Their Medicine

One of the biggest challenges in fighting tuberculosis is simply getting patients to take their medicine.


MIT students have come up with a possible solution: a new testing and reporting system that is easy for patients to use and offers economic incentives such as free cell phone minutes.


Tuberculosis kills an estimated two million people every year, and treating the disease requires a strict six-month regimen of antibiotics. If patients abandon the treatment early, the TB bacteria survive and can become resistant to first-line antibiotics.


"TB is a massive problem, and it's exacerbated by the fact that people have a lot of trouble staying on their meds," says Elizabeth Leshen, an MIT sophomore majoring in biological engineering and member of the team, known as "X Out TB."


The students' plan, which has been field-tested in Nicaragua, combines a newly developed paper testing strip with a simple text message reporting system to ensure drug compliance.


The team's novel test strip takes advantage of new technology known as paper microfluidics. The strip is embedded with chemicals that react with metabolites present in the urine of patients who have taken TB medicine. When the chemical reaction occurs, the strip changes color, revealing a number.


Patients are given a device that dispenses one strip every 24 hours, and after they successfully take the test, they have about two hours to text the number on the strip to a central database that records that they have taken the drug.


Patients whose compliance rate is high enough receive free cell phone minutes. The team decided on cell phone minutes as an incentive because it's fairly easy to set up the reward system, and because most of the target patients have a cell phone already.


"It's really easy to tell cell phone companies to give someone extra cell minutes. You don't need a new infrastructure," says Leshen, who joined the team last fall.


Susan Murcott, who teaches D-Lab III: Dissemination, is advising the team. She says she's impressed with the innovation shown by the students.


"There are a lot of creative elements," said Murcott, a lecturer in civil and environmental engineering. "They've engineered a better urinalysis test, you don't have to send somebody out every day to check that patients are taking their medication, and there are these incentives built into the program."


The new system could be a breakthrough in monitoring patients in developing countries who don't live near medical centers, says Jose Gomez-Marquez, who joined the team while a grad student at Worcester Polytechnic Institute and is now directing MIT's Innovations in International Health initiative.


"Some of these people live six hours from the nearest health care center, so telling them that they have to come in every day to check if they're taking their medication is a non-starter," he said.


Gomez-Marquez, who is from Honduras, also believes the project will transform the relationship between patients and health care workers.


"Their lives are so hard already, and the last thing they need is to become an example of disappointment in another person's eyes," he says. "We're turning that around and rewarding them for doing good."


The project got started as part of the 2006-2007 Muhammad Yunus Innovation Challenge to Alleviate Poverty, which challenged students to find a way to get TB patients to take their medicine. The Yunus Challenge, part of MIT's IDEAS Competition, is sponsored by Mohammed Abdul Latif Jameel, benefactor of MIT's Poverty Action Lab.


The "X Out TB" team decided that simply reminding people to take their medicine is not enough-the best way to get people to comply is to offer them an incentive. Similar incentive programs have been launched in the United States.



"This is a universal concept that, given the right technology, we think can be applied just as effectively in developing countries as it can here," says Leshen.


The team plans to run larger field tests in Pakistan and Indonesia this summer, in conjunction with local hospitals.


Other members of the team are Minyoung Jang '07, Elizabeth Gillenwater '07, Aron Walker '07, Angela Kirby '07 and Jeffrey Blander, lecturer in the Harvard-MIT Division of Health Sciences and Technology.


By Anne Trafton, News Office


mit

GuildNet Will Expand Use Of AMAC's Remote Telemedicine System To Improve Patient Medication Compliance

GuildNet, a managed long-term care program that offers a community-based alternative to facility-based long-term care, announced that after a three month evaluation period, it has decided to make American Medical Alert Corp.'s (AMAC) MedSmart Medication Management System available to its members. Wanda Figueroa-Kilroy, GuildNet's Executive Vice President, notes "our members and their families report a great deal of satisfaction with the device and we saw evidence that the reminders helped to ensure medication compliance."


Frederic Siegel, AMAC's Executive Vice President said, "We are very pleased with the results of the pilot and excited that GuildNet has decided to make MedSmart an integral part of their medication compliance program. With MedSmart, we are not only simplifying complex drug regimens, but putting providers and caregivers in the driver's seat to address dosing errors and ensure timely refill."


The MedSmart® System organizes, reminds and dispenses the correct pills at the correct time from 1 to 6 times per day ensuring safe and appropriate medication use. Using a two-way communication modem, MedSmart uploads device and dispensing information on a daily basis to a secure, web portal for access by authorized individuals. If a dose is missed or medications are low, the system will promptly notify designated caregivers via text, voice or email message, allowing for early intervention and timely tray refill.

Studies Geared To Improving HIV Care And Prevention Supported By Federal Stimulus Funds

UCSF HIV researchers have received two NIH grants of $1 million each to study the use of web-based, patient controlled personal health records to improve health and HIV prevention outcomes for HIV positive patients.



Both studies are funded through the federal stimulus bill, The American Recovery and Reinvestment Act.



One study will look at using mobile phone text messages linked to a web-based personal health record to help HIV patients' adherence to pill-taking regimens.



"Patients participating in the study will not only be assisted with taking their HIV medications, but also with medications for conditions like diabetes and hypertension. At least half the patients we see in our clinic have at least one other chronic disease that requires medication to control. Our hypothesis is that using individualized text message reminders linked to personal health records will help patients better succeed in self-management of their multiple health challenges," said James S. Kahn, MD, professor of clinical medicine at the UCSF Positive Health Program at San Francisco General Hospital.



Two methods will be used to assess adherence to medication regimens in this project. Self-report of pill taking is one. A biological marker, measurement of antiviral drug levels in hair, is the other method used. A member of the research team, UCSF assistant professor of medicine Monica Gandhi, MD, MPH, has shown this method to be a better correlate of success in HIV viral suppression during treatment than other variables usually considered.



The other study will test the feasibility and acceptability of a web-based strategy that seeks to reduce drug and alcohol use and accompanying HIV risk behaviors and improve antiretroviral medication adherence by HIV positive patients.



The strategy is called SBIRT and consists of screening for drug and alcohol use, a brief intervention and referral to treatment. It has been shown to be effective in many populations in reducing drug and alcohol use but has never been used in a HIV primary care setting. With several studies showing a relationship between high HIV transmission risk behaviors and drug and alcohol use, effective administration of the SBIRT strategy could also reduce HIV transmission according to the project team.



The project will compare SBIRT delivered through a self-administered and web-based method using patients' electronic health records with SBIRT delivered through a provider-administered protocol during clinic appointments using an electronic health record system.



"We want to see if the SBIRT approach will work in this population and this setting to not only reduce drug and alcohol use but also succeed in reducing HIV transmission associated with substance use. We are hoping to find out whether patients are more open to responding to sensitive topics with a self-administered web-based approach than they are talking directly with their clinician," said Carol Dawson-Rose, PhD, MSN, RN, associate professor of nursing at the UCSF Center for AIDS Prevention Studies.



Both studies use HERO (Health Care Evaluation Record Organizer), a web-based electronic medical record system and research database developed by Kahn and T. Van Nunnery, a programmer/analyst at UCSF, and myHERO. Integrated with HERO, myHERO is a publicly-accessible personal health record enabling patients to access information online from their own medical record. This complete electronic health record system is secure, flexible, extensible, and is exportable to other clinical care venues.

Non-Compliance May Be The Cause Of 'Difficult-To-Treat Asthma'

Difficult-to-treat asthma often may have more to do with patients who do not take their medication as instructed than ineffective medication, according to researchers in Northern Ireland.



"[A] significant proportion of patients with difficult asthma are poorly adherent to inhaled and oral corticosteroid therapy," wrote principal investigator, Dr. Liam Heaney, of Belfast City Hospital.



The results of the study were published in the November 1 issue of the American Journal of Respiratory and Critical Care Medicine, an official publication of the American Thoracic Society.



"Defining the scale and identifying non-adherence in this population is important given currently available and other imminent expensive biological therapies," said Dr. Heaney.



Dr. Heaney and colleagues obtained data from almost 200 patients who were referred to a tertiary referral clinic that specializes in treating difficult asthma. To assess compliance with inhaled corticosteroid therapy (ICT), they compared patient prescription to the patient's actual refill usage. They used blood plasma prednisolone and cortisol levels to evaluate oral medication adherence.



Of the 182 consecutive patients, 35 percent filled fewer than half of their prescribed inhaled combination therapy (ICT), 21 percent filled more than they were prescribed and 45 percent filled between half and all of the medication they were prescribed.



Furthermore, in patients who were on a maintenance course of oral prednisolone, blood levels of cortisol and prednisolone showed that nearly half (45 percent) were not taking the medication as prescribed. In follow-up conversations with the researchers, most admitted that they were inconsistent in the use of their medications. Of the 23 patients who were non-adherent to their oral prednisolone, 15 - or 65 percent - were also non-adherent to their ICT.



"All subjects had initially denied poor medication adherence, and poor adherence only became apparent using a combination of surrogate and objective measures," said Dr. Heaney. "Of these patients who were referred for assessment and treatment of difficult asthma, many are actually not taking their treatment as prescribed, which would suggest an important first course of action in assessing difficult asthma may actually be verifying the patient's adherence to his or her treatment protocol. Determining whether the patient is taking medications as prescribed is of utmost importance before moving to more aggressive and expensive treatments. It is also crucially important in understanding true refractory disease and assessing responses to novel therapies, either in clinical trials or clinical practice."



Some patient characteristics were more strongly associated with nonadherence than others: women were less likely to be adherent than men, a finding that had been previously identified, but that Dr. Heaney cites as needing more investigation.



Another red flag may be a lower score on quality of life measures. Dr. Heaney and colleagues found that patients who filled fewer than half of their prescribed ICT scored significantly lower on the EuroQol and the Asthma Quality of Life Questionnaire. Furthermore, the number of prior hospital admissions within the past 12 months was significantly associated with non-adherence.



"In general, one might expect in more severe disease that a very poor asthma quality of life score suggesting high morbidity, would perhaps, result in better adherence, " said Dr. Heaney. "The same could be said for hospital admission, but the reasons for non-adherence are complex. However for clinicians, multiple hospital admissions should definitely flag probable non-adherence in difficult-to-treat cases."



"Non-adherence is a common problem, which is often hard to detect. In general, asking the patient or relying on clinical impression is useless, and objective or good surrogate measures should be utilized. However, we need to try and develop better objective tests for this problem, and we are currently looking at some novel techniques to do this," Dr. Heaney concluded.

Chance Of Heart Failure Hospitalization Impacted By Health Literacy

Being able to read and understand words like anemia, hormones and seizure means a patient with heart failure may be less likely to be hospitalized, according to a new study from Emory University School of Medicine. Findings were presented at the American Heart Association Scientific Sessions conference in Chicago.



The research, led by Emory cardiologist Javed Butler, MD, MPH, professor of medicine, Emory School of Medicine and director of Heart Failure Research at Emory Healthcare, involved the use of a simple test called the Rapid Estimates of Adults Literacy in Medicine (REALM-R).



"This study lends more insight about the importance of health literacy and the impact it has on a patient's participation in their care," says Butler, who also serves as the deputy chief science advisor for the American Heart Association. "We learned that below optimal health literacy is driven by low socioeconomic status and is associated with increased admission rates in patients with heart failure."



REALM-R is a word recognition test designed to assist medical professionals in identifying patients at risk for poor literacy skills and playing a role in predicting their ability to control a chronic condition like heart failure. Adults are asked to de-code or pronounce a short list of words. The test takes less than two minutes to administer and score.



Emory researchers administered the REALM-R test to 154 heart failure outpatients from January 2008 to July 2009. People with a score of 60 or lower (considered low or marginal) had a 55 percent higher rate of hospitalization for any reason.



Among the 154 patients, 30 had a low REALM-R score. People with annual family income less than $50,000, African-Americans, and people without a college-level education were much more likely to have a low REALM-R score (ten-fold, five-fold and five-fold, respectively). Gender was not linked to REALM-R score.



What doctors call "hard events" (death, urgent cardiac transplantation, or ventricular assist device implantation) did not increase based on low REALM-R score.



The interdisciplinary study was co-authored by Emory University cardiovascular nursing researcher Sandra Dunbar, RN, DSN, FAAN, FAHA and Vasiliki Georgiopoulou, MD, assistant professor of medicine, Emory School of Medicine who also presented the study at the meeting.

The 'Silent Killer' Severe Hypertension Is Still On The Loose

High blood pressure may be one of the top killers in the country, but you'd never know it by the way we're behaving, say scientists attending the annual congress of the Society for Critical Care Medicine (SCCM).



"Research shows that some 73 million people in the U.S. have high blood pressure, yet many of them don't even know it. And among those that do, a large number are not taking the medications they need to control it," says Dr. Christopher Granger, a cardiologist at Duke University Medical Center. "We've discovered that these patients are getting highly variable treatment. Moreover, we also found out that we aren't doing a very good job following up with these folks once they leave the hospital," he adds.



Granger and colleagues at nearly two dozen institutions around the country created a special registry to find out what happens to patients with acute, severe hypertension - those with blood pressure readings above 160/110 - when they come to an emergency department or critical care setting for treatment.



They found that although 90 percent of them already had a diagnosis of high blood pressure, about a quarter of them were not taking the medicines they were supposed to. The researchers also found that extremely high blood pressure was related to high complication and death rates. Many of the patients already had major organ damage and over six percent of them died in the hospital. Upon discharge, most of the patients were given prescriptions for at least two medicines, but 41 percent had to be readmitted within three months. What may be most unsettling, however, is the fact that the investigators could not find any evidence in the discharge records of about 60 percent of the patients that there had been any attempt to schedule a follow-up appointment for them.



"We are apparently turning large numbers of patients back out into the community without appropriate follow-up and care," says Granger. "Severe hypertension is a very common problem, but we really know very little about it. There is a huge need to improve care for these patients."



Dr. Solomon Aronson, an anesthesiologist at Duke, sees danger in high blood pressure from another angle. Aronson has spent years trying to discover the "sweet spot," or ideal range, of blood pressure during cardiac surgeries. Aronson led a team of investigators that analyzed over 3 million blood pressure readings in the records of 5238 cardiac surgical patients at Duke over a nine-year period They discovered that when patients' systolic blood pressure readings fell below 95 or went higher than 135, there was a greater risk of death within the following month, with the risk of death increasing with the amount and duration of the deviation from that range.



"This is the first time that anyone has determined the optimal range for blood pressure management during these procedures," says Aronson, who adds that different ranges might be more appropriate for other types of surgery.



Aronson says blood pressure management has become such a routine responsibility during surgery that physicians may have developed an attitude of "therapeutic inertia." "These data suggest that drifting off the road and onto the shoulder when you drive is not good for you. We're beginning to define the width of the road."



"We still have a long way to go before we can understand and successfully manage the subtle and complex effects that targeted blood pressure control has on overall health," he says. "Just because high blood pressure is a common problem doesn't mean that we know how best how to deal with it."







Both Aronson and Granger are paid consultants for The Medicines Company, which supported the creation of the new, acute, severe hypertension registry at Duke and is also developing an experimental drug for the management of high blood pressure.

Insured African-Americans More Likely To Use Emergency Room Than Other Insured Groups

Health insurance, and the access it provides to a primary care physician, should reduce the use of a major driver of health care costs: the emergency room.



Yet in a policy brief released today by the UCLA Center for Health Policy Research, researchers found that in California, privately insured African Americans enrolled in HMOs are far more likely to use the ER and to delay getting needed prescription drugs than HMO-insured members of other racial and ethnic groups. The research was funded by the California Office of the Patient Advocate.



It's not that African Americans fail to see their doctors, researchers say. In fact, of all HMO enrollees, African Americans were the most likely to report seeing a doctor in the past year, according to the authors of the brief, "African-Americans in Commercial HMOs Are More Likely to Delay Prescription Drugs and Use the Emergency Room."



Patient income and illness did not predict ER or prescription drug use either. Researchers found greater ER use and delays in getting prescription drugs even among African American HMO enrollees who were generally healthy and had higher incomes.



While the reasons behind the ER use and drug delays among African Americans are the subject of future research, lead author Dylan Roby, a research scientist with the UCLA Center for Health Policy Research, said the data suggests that the way health maintenance organizations or their contracted physicians provide care - and the way patients respond to that care - may create obstacles to timely primary care, as well as foster excessive use of the emergency room and delays in getting needed medications.



African Americans Depend on HMOs



More than two-thirds of insured African Americans in California are enrolled in HMOs (67.3 percent, or 1.35 million), compared with 64.7 percent (4.5 million) of insured Latinos and 51.6 percent (8 million) of whites.



Using data from the 2007 California Health Interview Survey (CHIS), researchers found that African American patients enrolled in commercial HMO plans were more likely to delay getting needed prescription drugs. Those enrolled in commercial Kaiser Permanente plans were more likely to use the ER, they said.



"It's troubling, because it suggests that even if you are insured and well-off, you still may not be getting the care you need," Roby said. "It also suggests that HMOs that are designed to provide preventive care and to make sure people have their medications are not able to do so."



Kaiser Permanente is the most popular HMO among African Americans, with one-fourth of all insured African Americans enrolled in the Oakland-based insurance carrier. Despite HMO emphasis on preventive care, however, more than a quarter (25.4 percent) of all privately insured African Americans enrolled in a Kaiser Permanente plan used the emergency room in the past year - in contrast to 14 percent of Asian American enrollees and 17.5 percent of Latinos.
















The reasons could range from the relative affordability of emergency-room services to the ease of accessing those services, Roby said.



"If it takes days or weeks to get an appointment with your doctor and just hours to be seen in the ER, people might make the easier choice, especially if it is convenient and affordable," he said. "On the other hand, if someone knows their local ER is overcrowded and expensive, they may be more likely to wait and see their own doctor."



Delaying Needed Medicine



Privately insured African American HMO enrollees also were notably more likely to delay getting needed prescription drugs. Prescription drug delays were about 10 percent higher for privately insured African Americans enrolled in non-Kaiser commercial HMO plans than for whites in comparable commercial plans.



Costs, geography and the pharmacy benefits offered by a given HMO may all inhibit the timely purchase of prescription drugs.



"We need to think about how the cost of prescriptions and delays in getting needed medications are compromising health status and quality of life," Roby said.



The research helps health advocates in California identify key health and health care issues for African American HMO members, said Sandra Perez, director of the California Office of the Patient Advocate. "This is the first step in understanding how HMOs can close the gaps in the quality of care and access they provide to their members."



Roby recommended an education campaign for both patient and provider that would address appropriate use of the ER and primary care services, as well as the importance of medication adherence and getting prescribed medications and refills.



"African American HMO members need to be empowered to find a doctor they are comfortable with, while health plans need to make a greater effort to connect patients with that doctor," Roby said.



The policy brief was supported by a grant from the California Office of the Patient Advocate as part of a targeted educational outreach program.