Engaging Patients with Digital Tools: What We Think We Know

Patients who are engaged in their own care have better outcomes and cost the health care system less money. Creating the environment that supports patient engagement has been a recent focus across the United States, and digital tools have been suggested as an important piece of patient engagement. We discuss what we think we know about digital engagement, and present data of what is actually occurring.There’s no shortage of activity within the health information technology (HIT) space. Although our positions within a university afford us the opportunity to pick and choose when and how we will engage in the advancements that are rapidly confronting US hospitals and health systems, we anticipate that many of Hospital Pharmacy’s readers do not have that opportunity. From our e-mail exchanges with you and from talking with you at conferences, it’s clear that many of you face situations in which top-down decisions directly impact what your pharmacy department does as it relates to HIT. We focus this column on bringing you relevant HIT-related information.By the time you are reading this, the ALS Ice Bucket Challenge is likely to have given way to the next social media craze. But we believe that the Ice Bucket Challenge has implications that apply to the challenges and opportunities you face in your hospital setting. If you are not familiar with the Ice Bucket Challenge, take a few moments to search for it in your favorite browser. The challenge shows how social media, specifically social networks like Facebook, can provide a medium for rapid transmission of information; depending on the topic, the outcome of this rapid spread of information can have a significant impact. By the end of August 2014, the ALS Association received nearly $80 million in donations compared to $2.5 million for the same time frame in 2013.The use of Web 2.0 tools like social networks for health-related reasons is called Health 2.0. We have advocated that hospitals and health systems begin using Health 2.0 tools to engage their patients. Patient portals are a type of Health 2.0 tool that many hospitals have implemented to engage their patients. Portals are dynamic, collaborative, allow the access and management of information (by the patient or caregiver), and are largely patient-centric. Are all of your patients using your portal? Most likely they are not. Does that mean that no patients will use your portal? Also, most likely not. What about other Health 2.0 tools and emerging technologies that you are facing in your practice?We can draw on existing data to gain insight into what engagement you can likely expect from your patients. Biesdorf and Niedermann published a list of myths related to the use of Internet-based technologies and other emerging technologies for health-related reasons.¹ Susannah Fox provided her perspective on the myths, including specific data to support her argument that the myths are not true.² We will use these myths and Fox’s data to structure our presentation of data that we believe should be brought into discussion as your institution considers its plan for engaging patients.Myth 1: People don’t want to use digital services for health care. The Pew Internet Project (www.pewinternet.org) provides numerous examples that refute this myth. For example, 87% of American adults use the Internet, 70% of American adults have high-speed access at home, and, most notably, 72% of American adults have looked for health information online. Nearly 50% of adults look online for information for someone else. These “caregivers,” as they are called, are more likely to engage in online health activities like participating in support groups and contacting their providers.Myth 2: Only young people want to use digital services. The “older crowd” can be slower to adopt new digital tools, but this does not apply to all tools. For example, 87% of American adults are online. Among those 50 to 64 years of age, 88% are online. The percentage drops to 57% when we look at those 65 and older. Although there is less online participation in the oldest segment of the population, we are still looking at nearly 6 in 10 adults. Certainly, it’s not just the younger crowd using online tools.Myth 3: Mobile health is the game changer. This myth may seem to contradict previous articles we have written describing the potential value in mobile devices as tools to gather, analyze, and share health-related information, including information that the patient manages. Our rule of thumb with mobile is the same as with any technology – you must know your audience. Eighty percent of people with 2 or more chronic conditions track a health indicator. However, only 4% use an app to do so. We believe that patients’ use of apps is influenced by many factors, including general comfort with the device, concerns over security and privacy, lack of encouragement to use apps by trusted individuals (ie, providers), and a general wait-and-see attitude. We do believe mobile will profoundly change health care, but it is not there yet.Myth 4: Patients want innovative features and apps. For those adults who track health indicators, 49% keep track in their heads, 34% use paper records, and 21% use some form of technology. The message is clear that knowing who you serve and what fits their daily routine (as well as their comfort level) is paramount in designing tools to engage your patients.Myth 5: A comprehensive platform of services is a prerequisite for creating value. As your institution starts to digitally engage patients, it will be easy to identify a wide range of tools for immediate implementation based on the expectation that “if you build it, they will come.” We believe a systematic approach to selection and implementation is best. The process should be guided by direct input from the target users (ie, patients) in terms of what tools they believe they will use. Existing data and reports suggest that patients prefer portal-based communication tools like secure messaging over apps.In discussing the myths above, we have not touched on the pharmacist’s role in these activities. We believe that pharmacy should be involved in any discussions of technologies or tools that touch the medication use process at any time in the patient’s interaction with the health system, whether that is an acute stay, an outpatient experience, or an ambulatory clinic setting. We welcome your questions and comments about the work you have before you or the work you have completed related to engaging patients with digital tools (Brent at ude.nrubua@nerbxof and Bill at ude.nrubua@gbeklef).     

Population pharmacokinetic analysis of axitinib in healthy volunteers

AIMS

Axitinib is a potent and selective second generation inhibitor of vascular endothelial growth factor receptors 1, 2 and 3 approved for second line treatment of advanced renal cell carcinoma. The objectives of this analysis were to assess plasma pharmacokinetics and identify covariates that may explain variability in axitinib disposition following single dose administration in healthy volunteers.

METHODS

Plasma concentration–time data from 337 healthy volunteers in 10 phase I studies were analyzed, using non-linear mixed effects modelling (nonmem) to estimate population pharmacokinetic parameters and evaluate relationships between parameters and food, formulation, demographic factors, measures of renal and hepatic function and metabolic genotypes (UGT1A1*28 and CYP2C19).

RESULTS

A two compartment structural model with first order absorption and lag time best described axitinib pharmacokinetics. Population estimates for systemic clearance (CL), central volume of distribution (V_c), absorption rate constant (k_a) and absolute bioavailability (F) were 17.0 l h⁻¹, 45.3 l, 0.523 h⁻¹ and 46.5%, respectively. With axitinib Form IV, k_a and F increased in the fasted state by 207% and 33.8%, respectively. For Form XLI (marketed formulation), F was 15% lower compared with Form IV. CL was not significantly influenced by any of the covariates studied. Body weight significantly affected V_c, but the effect was within the estimated interindividual variability for V_c.

CONCLUSIONS

The analysis established a model that adequately characterizes axitinib pharmacokinetics in healthy volunteers. V_c was found to increase with body weight. However, no change in plasma exposures is expected with change in body weight; hence no dose adjustment is warranted.     

An analysis of T-cell receptor variable region gene expression in major histocompatibility complex disparate mice.

To define the impact of major histocompatibility complex (MHC)-encoded glycoproteins on the selection of the T-cell receptor repertoire, we have determined the frequency with which T-cell receptor variable region (V alpha and V beta) genes are expressed in T cells from MHC disparate mice. Approximately 500 T-cell hybridomas were generated from each of three strains of MHC congenic mice [B10 (H-2b), B10.BR (H-2k), and B10.Q (H-2q)] by fusing mitogen-stimulated lymph node T cells with the thymoma BW5147. RNA was prepared from 1629 individual hybridomas and analyzed for the expression of 10 V alpha and 16 V beta gene families. These experiments reveal significant differences in the relative contributions of 1 V alpha gene family (V alpha 3) and several V beta gene segments (V beta 5.1, -5.2, -11, and -12) to the T-cell receptor repertoire of MHC disparate mice.     

Electrocardiographic changes associated with isolated right ventricular infarction

Isolated infarction of the right ventricle is an extremely rare entity. A patient is described with diffuse interstitial lung disease who developed ST segment elevation in inferior and anterior leads on a routine electrocardiogram and at autopsy was found to have an isolated right ventricular infarct involving approximately 70% of the right ventricular circumference without involvement of the left ventricle and septum. This case illustrates that isolated right ventricular infarction in the presence of cor pulmonale and right ventricular hypertrophy can produce an injury current in the limb and precordial leads of the electrocardiogram which mimics that seen in typical transmural infarction of the left ventricle.     

Development and preliminary validation of the First Episode Social Functioning Scale for early psychosis

The current study aimed at developing and conducting a preliminary validation a novel social functioning measure for people with early psychosis. The First Episode Social Functioning Scale (FESFS) was developed to cover many domains specific to this population in their contemporary reality. The self-report version of the FESFS was administered to 203 individuals receiving services in first episode clinics. Scores of the GAF, SOFAS, Social Functioning Scale and BPRS were also obtained for parts of the sample to calculate convergent and discriminant validity. A subgroup also answered the FESFS at several time points during treatment in order to determine sensibility to change. Principal component factor analyses and internal consistency analyses revealed the following nine factors with alphas ranging from 0.63 to 0.80: Friendships and social activities, Independent living skills, Interacting with people, Family, Intimacy, Relationships and social activities at work, Work abilities, Relationships and social activities at school, Educational abilities. Convergent and discriminant validity were demonstrated, as well as sensitivity to change. Clinical and research utility of the FESFS are discussed.     

Factor structure of the Chinese version of the WAIS-R for Chinese adults in the lowest percentiles of IQ

The Chinese version of the WAIS-R was factor analyzed for a sample of 130 Chinese adults in Hong Kong who had low intellectual abilities. All subtests except the Vocabulary subtest were included for analyses. Results supported a three-factor solution composed of Verbal Comprehension, Perceptual Organization, and Memory/Freedom from Distractibility Factors, as well as a two-factor solution of classic Verbal-Perceptual dichotomy. Comparison of present two- and three-factor structure with individuals having low or normal IQ in Mainland China and North America revealed satisfactory congruence coefficients. However, our general factor accounted for only a small portion of common and total variance (28.5% and 35.3% respectively). Error variances of our subtests were large when compared to normative samples of Mainland China and US. Results were discussed in terms of clinical interpretation of the WAIS-R subtests, danger of using short-forms to assess IQ and need for normative studies of WAIS-R in Chinese-speaking countries. © 1996 John Wiley & Sons, Inc.     

Maternal exposure to paternal HLA does not explain the postpartum increase in rheumatoid arthritis

The postpartum period, particularly after the first pregnancy, represents a time of increased risk for the development of rheumatoid arthritis (RA). The present study was undertaken to investigate whether this increase in risk may be due to maternal exposure to fetally inherited paternal HLA-DR antigens that were either 1) similar to their own or 2) had an increased likelihood of being one of the two specific types, HLA-DR1 and DR4, implicated in the etiology of RA. We recruited 94 families where the mother had developed RA within 12 months of a pregnancy, and HLA typed the mother, father, and relevant child of each family. Mothers were not more likely to share HLA-DR genes with their partners than would be expected, and children whose parents shared one HLA-DR gene were not more likely to inherit the shared gene from their father as opposed to the non-shared gene. Further, those children whose fathers were heterozygous for HLA-DR1 or DR4 were not more likely to inherit these genes as opposed to the non-DR1/DR4 gene. In conclusion, maternal exposure during pregnancy to either fetally inherited paternal HLA-DR1 and DR4 genes or to paternal DR genes similar to their own does not appear to contribute to postpartum maternal susceptibility of RA. © 1996 Wiley-Liss, Inc.