1. REMOTE DOT – LESSONS LEARNED FROM ADOLESCENT ADHERENCE
LESLEY KENNEDY
ASTHMA / ALLERGY NURSE SPECIALIST
R.B.H.S.C.

2. DEFINITIONS OF ADOLESCENCE
… “ Adolescence is the period of your life in which you develop from being a child into being an adult…” …. “the transitional period between puberty and adulthood in human development, extending mainly over the teenage years and terminating legally when the age of majority is reached; youth…” Defined by WHO as being between 10 and 19 years of age. “ Adolescence is like having only enough light to see the step directly in front of you.” Sarah Addison Allen (Author)

3. ADOLESCENCE- WHAT???? 7.2 billion people world wide
3 billion are younger than 25 years of age = 42% of the world’s population
1.2 billion are adolescents aged between 10 and 19 years of age
WHO – Global Accelerated Action for the Health of Adolescents 2018

4. CHALLENGING TIME OF LIFE
Learn behaviours
Establish relationships
Develop independence
Develop social skills
ADOLESCENCE
CRITICAL
&
CHALLENGING TIME OF LIFE

5. NRAD REPORT 2014
1:11 children and 1:12 adults in the UK have asthma – adolescents overlap both age groups (Asthma UK)
Looked at 195 asthmatic patients who died
18 were aged 10–19 years
13 out of 18 of those aged 10–19 years died before even reaching hospital
Royal College of Physicians. Why asthma still kills? The National Review of Asthma Deaths (NRAD) [online] Available from: [Last accessed: March 2018]
Levy, M.L., 2015 The national review of asthma deaths: what did we learn and what needs to change? Breathe, 11(1), p.14.

6. ASTHMA AND ADOLESCENCE
AIMS OF ADOLESCENCE CLINIC
BTS GUIDELINES 2016 section 11 pg ASTHMA IN ADOLESCENTS
- recommends empowerment :

7. Lots for the adolescent to learn and in some instances lots to unlearn!

8. GINA GUIDELINES GOALS
The GINA guidelines specify eight goals for the long-term management of asthma:
Minimal chronic symptoms
Minimal exacerbations
No emergency visits
Minimum need for as-required b2agonists
No limitations to daily activities
Near normal peak expiratory flow (PEF)
PEF circadian variation <20%
Minimal adverse effects from asthma medication.
(Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. NHLBI/WHO workshop report. National Institutes of Health, National Heart, Lung and Blood Institute. January 1995, NIH publication number 95±3659).

9. INHALER TECHNIQUE AND ADHERENCE
The Asthma Insights and Reality in Europe (AIRE) survey Multinational survey assessing the level of asthma control among asthmatics in Western Europe from the patient's perspective Provides the best estimate currently available of how well the goals of the GINA guidelines are being met In the AIRE survey, bronchodilator (SABA) use was at least 3 times greater than ICS use over a 4-week period in children across all severities = Poor Adherence
Reliever
Preventer
ICS, inhaled corticosteroid; SABA, short-acting β2-agonist.
Rabe KF et al. Eur Respir J 2000;16:802–7.

10. HURDLES WORKING WITH ADOLESCENT ASTHMA PATIENTS
ARE THERE ANY?
Over-reliance on a SABA is common in adolescents
Over-reliance on a SABA and low adherence to controller therapy develops in adolescence and is prevalent in adulthood
“I feel my blue inhaler working better than my other one”
Desai M, Oppenheimer JJ. Curr Allergy Asthma Rep. 2011;11:454–464;
McQuid EL, et al. J Ped Psychol. 2003;28:323–333;
Price D, et al. NPJ Prim Care Respir Med. 2014;24:14009;
Partridge MR, et al. BMC Pulmon Med. 2006;6:13.

11. Has inhaler technique and adherence not improved?
2 RECENT STUDIES :
Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time? Chest. 2016 Aug;150(2):
Over 50,000 subjects –prevalence of correct inhaler technique 31%
Incorrect technique is frequent and unacceptable
Has not improved over the past 40 years
Behavioural Interventions to Improve Asthma Outcomes for Adolescents: A Systematic Review JACI: In practice. 2016; 4(1): 2016,130–141
Suggests some strategies to increase adolescent adherence to preventative medication including
monitoring and providing feedback
using school nurses for directly observed therapy

12. BTS 11.12.2 - ADHERENCE Confused about their medication
Adherence with asthma treatment and trigger avoidance is often poor in adolescents – results from questionnaires and qualitative studies.
(Bender, Rankin et al Brief interval telephone surveys of medication adherence and asthma symptoms in the Childhood asthma Management Study. Ann Allergy Asthma Immunol 2008; 101(4):382-6)
Confused about their medication
Don’t understand why they need to take it – don’t accept their diagnosis
Can’t be bothered
Stigma of being asthmatic and the embarrassment around their friends
Forget
Don’t like their inhalers – device, taste, colour
Worried about side effects of “steroids”

13. Strategies to check & improve adherence
Northern Ireland – NIECR
Last prescription ordered
Visits to OOH / ED or IP admissions also attendances at OPDs
Request repeat prescribing from GP
Home Visits – once a day for a week
School nurse directly observed therapy

14. Device Specific Strategies
INCA – Inhaler Compliance Assessment Device
Inhaler adherence was improved by 7 % in 3 months
Looks at compliance and inhaler technique based on audio recordings of peak inspiratory flow when taking the inhaler.
(D’Arcy, MacHale et al 2014 “A method to assess adherence in inhaler use through analysis of acoustic recordings of inhalers events.”)
Smart Inhaler electronic monitors
Record the time and date of inhaler use
Transmit the information to the patient’s mobile and their doctor.

15. Have you ever……?
Wished you could actually move in to a house to see what is happening with asthma treatment
Suspected that the symptoms you are hearing about from the teenager could be improved with regular asthma treatment - which has already been provided but you suspect isn’t taken.
Wanted to find the best way to ensure that adolescents have developed good habits
I VERY OFTEN DO

16. R-DOT
WHAT IS IT? Remote Directly Observed Therapy Visual / audio recording through a secure APP used with asthmatics in RBHSC to optimise asthma therapy ensuring correct inhaler technique, make sure oral medication is taken and improve adherence.

17. Why use it? Pilot study in RBHSC 2016 AIMS – Evaluate feasibility
Shields, Alqahatani et al 2017 “Using remote directly observed therapy (R-DOT) for optimising asthma therapy”
AIMS –
Evaluate feasibility
Clinical impact of R-DOT on – inhaler technique
- adherence to treatment
Focus on children and young people with partially controlled or uncontrolled asthma

18. Slide courtesy of Prof. MD Shields
RBHSC /QUB 2017

19. Methodology Baseline FeNO / ACT / QoL done before study
Participants to capture a R-DOT video twice daily (morning and evening) on their mobile devices of ICS use by the patient.
Feedback to participants given by nursing staff
Phone call or text if missed two days uploads
Parents contacted by clinic staff if R-DOT videos demonstrated poor technique

20. Results
All children were able to demonstrate proper inhaler technique using “Teach to Goal” however 80% making mistakes in the 1st week
12 weeks post intervention
FeNO reduced from average of 40 ppb to 18 ppb
ACT scores rose from to 18
QoL Scores 3.27 – 5.25
Slide courtesy of Prof. MD Shields
RBHSC /QUB 2017

21. Conclusion of Pilot Study
Despite being able to demonstrate correct inhaler technique at clinic only 20% had correct technique at home
R-DOT
Is feasible and convenient to use
Allows corrective feedback
Is affordable and easy to use
Can be used with any type of inhaler, nasal or oral therapy
The R-DOT app can be used as a tool for improving
medication adherence,
inhaler technique and
asthma control in children or young people with uncontrolled asthma.

22. Features of rDOT For Patients For Healthcare Providers
Patient Enrolment
Flexible and convenient
Can be used to improve or maintain treatment adherence
Reduce travel burden for patients who live in rural areas with restricted  access  to  medical staff and resources
Can be used as communication tool between patient and medical staff e.g. discussion on medication side effects
Can be used for monitoring adherence of immobile and disabled patients
Enrol patients into directly observed therapy, creating a personalised care plan.
Patient Review
Review patient treatment administration, and provide feedback and corrections remotely.
Medication Reminders
Patients receive automated reminders of medications,
as defined by their care plan.
For Healthcare Providers
Feedback
Reduced number of medical staff needed for observation
Saves staff time on transport to visit patients at home
Cost effective approach compared with traditional DOT
Can be used to observe patients taking medication at the weekend and public holidays
Patients receive notifications of feedback when reviewed
by their healthcare provider.

23. Personal Experience of R-DOT
Gets a good habit established with all medication
Consistently correct inhaler technique
Improved lung functions – increased PFTs and decreased FENO
Improved ACT (Asthma Control Test) scores
Improved PAQLQ Paediatric Asthma Quality of Life)Scores
Feel so much better and want to stay that way
I can see the patient
“ My friends notice a real difference in me”
“I can now run on the treadmill at the gym”
“ I can play football now without having to sit out as much ”
“ I am not using as much blue inhaler ”
“I feel much better now”

24. Realistically – there are some issues?
Pressure from family to fail – excuses made once they realise this will reduce asthma symptoms = financial rewards of poor control lost
App wouldn’t work
Phone broken or lost or both!
Left inhalers on the bus and the GP won’t prescribe more
Poor quality videos sent
Some with poor technique but refused to correct it
Poor inspiration
Nasal spray sprayed anywhere but not up the nose / use of inhaler without aerochamber

25. Adolescent Patient Examples
15 year old always symptomatic - inhalers increased more medication added. Relvar 184/22, Dymista, Bambec, Cetirizine, Montelukast, Salbutamol Always coughing, ↑ rhinitis symptoms, OCS courses +++ Poor lung functions and poor effort doing lung functions Increased IgE to dogs which they have 3 at home. (Home Visit) Made clear to parents and patient - high risk of severe life threatening attack or death from an acute exacerbation. RESULT – Dogs were removed / smoking cessation advice to parents BUT still increased symptoms – attended adolescent clinic / parents asked about DLA appeal. Bad form wanted to go to the gym and was fed up being unable to exercise with friends. Fed up wakening through the night a with blocked nose 6 weeks R-DOT – improved lung function / improved QoL / able to exercise / parents decided asthma control was better than DLA.

26. Patient 2
16 year old History of anxiety - referred because of increased shortness of breath and chest tightness which was getting worse. Reversibility of PFTs was 40% / investigations and history pointed to a diagnosis of asthma. Decided on a trial of ICS then combination treatment using SMART PROBLEM - this adolescent wouldn’t accept the diagnosis and made every excuse not to take the treatment. Worsening of symptoms poor school attendance and ↓QoL Referral to adolescent clinic after being changed to Relvar once daily for education and R-DOT Discussed and agreed to 6 weeks R-DOT -agreement that if there was improvement in quality of life and a reduction in symptoms THEN – acceptance of diagnosis with lots of discussion!!! and also continued compliance to treatment OUTCOME – improved attendance at school / much happier now / compliant

27. ANY QUESTIONS?