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Service Delivery Innovation Profile

Weekly Feedback to Patients on Use of Rescue Medications Leads to Better Asthma Control


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Snapshot

Summary

Individuals with asthma receive weekly reports via e-mail that provide detailed information on the times and places that they have used rescue medications (tracked by a Global Positioning System device attached to the rescue inhaler) and daily controller medications (tracked through an electronic diary completed by patients), along with guideline-based recommendations designed to help the individual better control his or her asthma. Users can also proactively access this information via an online or mobile application at any time. Depending on clinician and patient preferences, any of this information can potentially be made available to physicians, and aggregated, deidentified data can also be made available to public health officials and individuals. Although only certain components of the program have been evaluated, the weekly e-mail reports providing information and guidance related to rescue medication use have improved asthma control, reduced asthma-related symptoms, and enhanced knowledge and awareness about the disease and adherence to use of preventive medications.

Evidence Rating (What is this?)

Moderate: The evidence relates to one aspect of this multifaceted program (weekly reports on rescue medication use) and consists of a small (27-person), short-term (3-month) study evaluating trends in asthma control scores and asthma-related symptoms, limitations, and nocturnal awakenings, along with anecdotal reports from those receiving the weekly reports.
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Developing Organizations

Asthmapolis; Reciprocal Sciences
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Date First Implemented

2009

Problem Addressed

Many individuals have asthma, and the majority of them face significant challenges in keeping the condition under control. Poor asthma control frequently leads to exacerbations and worsening of symptoms that negatively affect quality of life and often result in costly emergency department (ED) visits and inpatient admissions. Ongoing self-monitoring and self-management can improve asthma outcomes, but few patients have access to effective support to help with these tasks.
  • Many individuals with uncontrolled asthma: Asthma, a chronic inflammatory disease of the airways, affects more than 23 million Americans.1 Many individuals with asthma do not have the condition under control, including one-half to two-thirds of asthma patients in the United States and over half of asthma patients in Canada (where asthma control has not improved in the last decade).2
  • Leading to impaired quality of life, need for costly care: Poor asthma control frequently leads to impairment and activity limitations, has a negative impact on quality of life, and can lead to the need for costly ED and inpatient care.3 Asthma causes nearly 500,000 hospitalizations each year; in 2010, asthma-related treatment in the United States is projected to cost $20.7 billion.1
  • Lack of access to effective self-management support: Patients can often keep their asthma under control by monitoring use of preventive and rescue medications and by following a written action plan. But many patients do not even realize that their asthma is not being well controlled, as they have unrealistically low expectations as to how well asthma can be managed. These patients need education and support, but busy primary care providers often lack the time or staff to provide such support; consequently, many patients either lack up-to-date action plans or do not understand how to implement them.4 Some providers ask patients to fill out paper-based logs that track medication use, symptoms, and other key data, but many patients do not fill out such logs or fail to do so regularly (leading to inaccurate information, as patients fill out the log from memory right before visiting the doctor). As a result, physicians have few useful tools to assess how well their patients are doing in controlling asthma in the community.

What They Did

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Description of the Innovative Activity

Individuals with asthma receive weekly reports via e-mail that provide detailed information on times and places that they have used rescue medications (tracked by a Global Positioning System or GPS device attached to the rescue inhaler) and daily controller medications (tracked through an electronic diary completed by patients), along with guideline-based recommendations designed to help the individual better control asthma. Users can also proactively access this information via an online or mobile application at any time. Depending on clinician and patient preferences, any of this information can potentially be made available to physicians, and aggregated, deidentified data can be made available to public health officials and individuals. Any or all elements of this program can be used according to the preferences of the adopting organizations; a description of each of the potential components appears below:
  • Tracking of medication use: The program tracks use of both rescue medications and daily controller medications, with each currently monitored through a separate process, as outlined below:
    • Device to track rescue medication use: A small GPS device attached to the inhaler records and stores the time and location of every use of rescue medication by a patient. Such information can be important to ongoing management of asthma. For example, how often a person uses such medications represents an important indicator of how well their disease is being managed and offers a valuable warning sign of worsening asthma. Similarly, information on the time that rescue medications are used can be valuable, as nocturnal symptoms and medication use signals worsening asthma. Depending on the version of the device (known as SpiroScout) being used, this information is either automatically relayed to a central server via cellular networks or can be downloaded by the user to a computer and securely relayed using special software through the Internet. (Users of this latter approach are encouraged to download and send the information every few days.) Since the device is not approved as a dose counter, it tracks rescue medication events rather than the specific amount of medication used per event. It uses a rechargeable battery that lasts 2 to 3 days per charge for the version requiring computer download, and 5 to 7 days for the version using cell phone data transmission.
    • Electronic diary to track controller medication use, symptoms, and triggers: Rather than using paper-based logs, those with asthma can access a Web-based diary via a computer or any mobile device with a Web browser (e.g., cell phone) to input information on use of daily medications, asthma-related symptoms and triggers, and other important asthma-related events. The system can also be set up to remind and encourage individuals to take their daily controller medication if they have not entered information into the diary. (In the future, the GPS device described above will also be used to track some classes of daily controller medications, thus eliminating reliance on input into the electronic diary for these medications.)
  • Weekly summary reports to support self-management: On a weekly basis, those with asthma receive an e-mail report that summarizes key information on asthma control. This e-mail includes maps showing where the person has used rescue medications during the week (including how many individual attacks have occurred at each location), adherence to the daily controller medication regimen and triggers that they have noted (assuming the individual has filled out the electronic diary), and charts and tables that display trends and patterns related to medication use and adherence over time. The weekly report also includes customized messages based on National Asthma Education and Prevention Program (NAEPP) guidelines; for example, someone who has used rescue medications many times during the week and/or who has routinely missed taking controller medications will see a message indicating that his or her asthma seems to be out of control, and emphasizing the importance of following the prescribed medication regimen.
  • As-needed online access to information: At any time, an individual can securely log onto a Web site that provides an updated, real-time version of the same kinds of information contained in the weekly e-mail. Individuals can also add or edit information through this system about their condition, such as frequency and severity of symptoms.
  • Clinician access to information: Any of the information provided to someone with asthma can also be given to that person's clinician(s); this information can then be used to guide inperson visits, including physician–patient discussions about self-management and asthma control. The system can be customized to provide information to clinicians based on their preferences for receiving information; for example, most physicians will not want to be alerted every time a patient uses a rescue inhaler, but rather would likely prefer to receive periodic reports (e.g., monthly, quarterly, in advance of a scheduled visit with a patient) with information similar to that provided in the summary report described above.
  • Aggregated, community-wide information for public health and individuals: By aggregating deidentified data from multiple users, this program provides real-time, community-wide information, including data on the burden of asthma in a community and on particular geographic areas where outbreaks of asthma exacerbations may be occurring. Such information can be used by public health officials and others involved in public health, and by individuals with asthma who might want to avoid these areas. Currently, public health officials often rely on outdated and limited information, such as historic data on asthma-related ED visits and hospitalizations. By contrast, this approach has the potential to allow public health officials to better target interventions and to evaluate the effects of these interventions, and to identify in real-time situations and geographies where exacerbations have the potential to create a surge in demand for clinic, ED, and hospital services, and/or the potential to cause spikes in missed work and school days. Officials can use this information to inform affected stakeholders (e.g., hospitals, schools, employers) and to alert residents.

Context of the Innovation

Founded in 2007 as Reciprocal Sciences, LLC and reincorporated in 2010, Reciprocal Labs Corporation is a small, for-profit company that develops products and services for public health agencies, health care companies and organizations, and clinical and epidemiological research teams. The company developed the SpiroScout device that attaches to rescue inhalers so as to track the frequency and location of asthma attacks. Asthmapolis, which is developed and owned by Reciprocal Labs Corporation, creates mobile and desktop software and data collection and analytical tools that take information from tracking devices so as to allow useful feedback to individuals and communities to improve asthma control. Asthmapolis has several projects underway, including research to better understand patterns of asthma morbidity, air pollution exposure, and the development of asthma symptoms, and interventions to remotely monitor and improve adherence with controller medications. Company leaders believe that much of the burden of asthma could be prevented by providing better information that facilitates proper treatment and effective public health surveillance.

Did It Work?

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Results

Although only certain components of the program have been evaluated, the weekly e-mail reports providing information and guidance related to rescue medication use have improved asthma control, reduced asthma-related symptoms, and enhanced knowledge and awareness about the disease and adherence to use of preventive medications.
  • Better asthma control: Among 27 individuals with asthma who received the weekly reports on rescue medication use, the average asthma control score (a composite measure based on responses to survey questions related to specific symptoms, such as activity limitations and breathing difficulties) rose from 18.6 at implementation to 21.2 2 months later, a statistically significant increase. Before the launch of the weekly reports, these same individuals spent 1 month getting used to having the GPS device attached to their inhaler; during this month, average asthma control scores rose modestly, from 17.8 to 18.6, but this finding was not statistically significant.5
  • Fewer symptoms (but not activity limitations or nocturnal awakenings): During the 2-month period outlined above, the number of days when participants experienced asthma-related symptoms fell significantly. Before the weekly reports commenced, the typical user reported asthma symptoms on roughly 5 of the preceding 14 days; after 2 months, that figure had dropped to approximately 1 out of the last 14 days. Declines did not occur, however, in the number of days with activity limitations or nocturnal awakenings.5
  • Enhanced knowledge, awareness, and adherence to preventive medication regimen: Anecdotal reports suggest that those receiving the weekly reports have enhanced their knowledge and awareness of asthma, leading to better adherence, as outlined below5:
    • Greater awareness: Many participants found that the weekly reports made them more aware of where their asthma attacks most commonly occur, including several who discovered, to their surprise, that their attacks generally occur outside the home. The reports helped one participant learn that attacks tend to occur at work (something not realized previously); another participant used the reports to notice time-of-day patterns related to rescue inhaler use, and a third participant discovered that use of the rescue inhaler occurred much more frequently than previously thought.
    • Better understanding: Several individuals felt they developed a better understanding of their asthma from the weekly reports. For example, one now notes the surroundings when shortness of breath occurs, and hence has become more aware of triggers missed in the past. Another individual with asthma noted that the weekly reports made it clear that the condition had not been adequately controlled in the past, which became the focus of the patient's discussion with the doctor at the next clinic visit.
    • Better adherence to preventive medication regimen: Some individuals have increased their adherence to daily controller medications since getting the reports. For example, one person noticed that rescue medication use went down significantly when controller medication was used, causing this individual to begin using the daily medication more regularly and at the appropriate time of day.

Evidence Rating (What is this?)

Moderate: The evidence relates to one aspect of this multifaceted program (weekly reports on rescue medication use) and consists of a small (27-person), short-term (3-month) study evaluating trends in asthma control scores and asthma-related symptoms, limitations, and nocturnal awakenings, along with anecdotal reports from those receiving the weekly reports.

How They Did It

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Planning and Development Process

The planning and development process will vary depending on the needs of the organization adopting this approach; general steps involved in this process include the following:
  • Gathering input from patients: Program leaders work closely with patients to develop an approach that does not create an undue burden. For example, before the initial pilot test, leaders worked closely with a group of five patients. Through pilot testing with them, the design of the GPS device changed several times. For example, the device initially made a beeping noise to confirm that an event (i.e., rescue inhaler use) had been captured. Patients did not react well to this noise, as it prevented them from using their inhaler discreetly in public.
  • Eliciting feedback from clinicians: Program leaders have conducted detailed interviews with physicians and other clinicians so as to understand how the system could provide them with information that would be valuable in making clinical decisions without disrupting workflow. Similar discussions take place on an ongoing basis with clinicians at any organization interested in adopting the program.
  • Training patients: Program developers created a user guide and instructional video to teach those with asthma how the device works, including how to charge it, what to do if it breaks, and how to use and install the software to transmit the data to the server (if applicable). To supplement these materials, participating individuals with asthma receive one-on-one training designed to familiarize them with the device and how it operates, and with the charts, maps, and other information available through the weekly e-mail reports and the secure Web site. As part of this process, participants receive their login credentials and learn how to access and add to the Web-based information.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as patients and clinicians incorporate it into their daily routines. Any labor associated with collecting, analyzing, and feeding back information to patients and clinicians will be handled by program developers as part of a licensing fee.
  • Costs: The costs for an organization interested in adopting this approach would be covered through a monthly, per-device licensing fee that includes the device along with data collection, analysis, and feedback. Pricing varies depending on the services desired, including when, how, and to whom (i.e., patients, clinicians, or both) the feedback information is provided.
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Funding Sources

Centers for Disease Control and Prevention; Robert Wood Johnson Foundation
The Centers for Disease Control and Prevention (CDC) has funded and continues to fund several projects to test the provision of feedback via weekly e-mail reports to asthma patients, including tests of newer systems that rely on mobile transmission of data (rather than downloading to a computer) and that track use of daily medications. The Robert Wood Johnson Foundation provided funding to support the work of David Van Sickle, PhD, as a postdoctoral fellow at the University of Wisconsin School of Medicine and Public Health. This funding ended in 2009.end fs

Tools and Other Resources

More information on Asthmapolis is available at: http://www.asthmapolis.com.

Adoption Considerations

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Getting Started with This Innovation

  • Involve patients and clinicians: Patients and clinicians can easily become overwhelmed with too much data, causing them to ignore the information provided through this program. To avoid this problem, work closely with patients and clinicians during the planning stage to create a system that provides the right amount of information at the right time in the right format for the user. During pilot tests, those with asthma strongly preferred to receive weekly summary reports via e-mail, rather than being forced to proactively access the Web-based system to view the same information. For their part, clinicians expressed a strong desire not to receive too many alerts (e.g., every time a patient uses rescue medication), and to receive feedback that fits into (rather than disrupts) the existing workflow. Different clinicians will likely have different views as to how this process should work.

Sustaining This Innovation

  • Change system in response to feedback: Regularly check in with patients and clinicians using the system to ensure that it continues to meet their needs, and make adjustments as possible in response to complaints and concerns. As noted earlier, the beeping sound made by the original device proved to be very unpopular with patients, causing program developers to rework the system so as to eliminate the noise.
  • Consider use with other chronic conditions: The same approach could potentially be used for other chronic diseases, particularly chronic respiratory conditions. For example, program developers are making the GPS device available to a physician investigator who has secured funding to test a similar program for monitoring and managing patients with chronic obstructive pulmonary disease.

Spreading This Innovation

Various aspects of the program are currently being tested by several organizations, including the Air Pollution and Respiratory Health Branch of the CDC, Health Canada, and the University of Wisconsin School of Medicine and Public Health. The New York State Department of Health and the University of Pittsburgh Medical Center (now officially known as UPMC) will also be implementing this program.

Additional Considerations

At present, the GPS devices, mobile phone application, and associated tools can be leased by researchers involved in surveillance programs, chronic care management programs, and other research-related studies; interested researchers should contact the program developer. A decision has not yet been made as to whether to make the devices and applications commercially available.

More Information

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Contact the Innovator

David Van Sickle, PhD
Post-Doctoral Fellow
Department of Population Health Sciences
University of Wisconsin School of Medicine and Public Health
610 Walnut St., 707 WARF
Madison, WI 53726

Reciprocal Labs Corporation
612 W. Main St, Suite 201
Madison, WI 53575
(608) 251-0470
E-mail: david@asthmapolis.com

Innovator Disclosures

Dr. Van Sickle is the majority owner of Reciprocal Labs Corporation.

References/Related Articles

Van Sickle D, Magzamen S, Truelove S. Online Feedback About Remotely Monitored Inhaled Bronchodilators Improves Composite Measures of Asthma Control. Thematic Poster Session at Asthma Epidemiology: Clinical and Pharmacological Determinants of Asthma Outcomes, held May 17, 2010. Abstract available in the online abstracts issue of the American Journal of Respiratory Critical Care Medicine; 2010;181:A3127.

Footnotes

1 National Heart, Lung, and Blood Institute. Morbidity & Mortality: 2009 Chart Book on Cardiovascular, Lung and Blood Diseases. Bethesda, MD: National Institutes of Health; 2009.
2 McIvor RA, Boulet LP, FitzGerald JM, et al. Asthma control in Canada: no improvement since we last looked in 1999. Can Fam Physician. 2007;53(4):673-7, 672. [PubMed]
3 Chen H, Gould MK, Blanc PD, et al. Asthma control, severity, and quality of life: quantifying the effect of uncontrolled disease. J Allergy Clin Immunol. 2007;120(2):396-402. Epub 2007 Jun 11. [PubMed]
4 National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94-138. [PubMed]
5 Van Sickle D, Magzamen S, Truelove S. Online Feedback About Remotely Monitored Inhaled Bronchodilators Improves Composite Measures of Asthma Control. Thematic Poster Session at Asthma Epidemiology: Clinical and Pharmacological Determinants of Asthma Outcomes, held May 17, 2010. Abstract available in the online abstracts issue of the American Journal of Respiratory Critical Care Medicine; 2010;181:A3127.
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Original publication: August 18, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 02, 2014.
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