This document discusses using interactive voice response (IVR) technology to improve statin adherence through targeted communications. It summarizes a statin adherence program at Kaiser Permanente Riverside that used IVR reminder calls, a barrier survey, and mail order options. The program reached 88% of the target population and 71% heard messages. It found the main barriers to adherence were not knowing to refill, cost, and convenience issues. Targeted messaging increased adherence, with 27% of those initially not intending to refill doing so after barrier messages. The program demonstrated how data and continuous improvement can enhance IVR's ability to personalize outreach at scale.

1. Improving Statin Adherence through
Interactive Voice Response (IVR) Technology
& Barrier Breaking Communications
Ananda Nimalasuriya, MD
Chief of Endocrinology
Kaiser Permanente Riverside California
George Van Antwerp, MBA
General Manager of Pharmacy Solutions
Silverlink Communications

2. Learning Objectives
• Understand the key barriers to statin adherence
• Learn how IVR communications can be
leveraged to drive statin adherence and address
specific barriers
• Learn how to use continuous quality
improvement for better communications
effectiveness
2

3. Agenda
• The long‐term impact of controlling blood
cholesterol levels
– The dangers and prevalence of high cholesterol
– The impact on clinical outcomes and cost
– The importance of statins in lowering and controlling
cholesterol
– The challenge of non‐adherence to statins
3

4. Agenda (cont’d)
• Statin Adherence Program
– Hypothesis & goals
– Program tactics & details
– Program results & barrier survey
• The Impact of IVR Technology
– Using personalized communications
– Collecting barrier information to deliver targeted educational
messages
– Leveraging champion / challenger to improve outcomes
• Q&A
4

5. If medication adherence was a
disease, it would be an epidemic.
The estimated annual costs of
non‐adherence is $290B.
Source: NEHI, 2009
5

6. High Cholesterol & Atherosclerosis
Coronary heart disease
•
Stable angina, acute myocardial infarction, sudden death,
unstable angina
Cerebrovascular disease
•
Stroke, TIAs
Peripheral arterial disease
•
Intermittent claudication, increased risk of death from heart
attack and stroke
CHD risk equivalents
•
•
•
Other clinical forms of atherosclerotic disease (abdominal
aortic aneurysm, symptomatic carotid artery disease)
Diabetes
Multiple risk factors that confer a 10‐year risk for CHD >20%
6

7. Major Causes of Death in the U.S.
Source: NCHS
Deaths: Final Data for 2007
7

8. _______________________________________________________________________________
Lifetime Risk of CHD Increases with
Serum Cholesterol
Cholesterol Level
Source: Framingham Study: Subjects age 40 years
DM Lloyd‐Jones et al Archives Internal Medicine 2003; 1966‐1972
8

9. Population vs. High‐Risk Approach
10
Percent of Population
Percent of Population
10
8
6
4
2
0
200
300
Serum Cholesterol Level (mg/DL)
•
•
•
6
4
2
0
100
•
8
400
100
200
300
400
Serum Cholesterol Level (mg/DL)
Risk factors, such as cholesterol or blood pressure, have a wide bell‐shaped distribution, with a “tail”
of high values.
The “high‐risk approach” involves identification and intensive treatment of those at the high end of
the “tail”, often at greatest risk of CVD, reducing levels to “normal”.
Most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur
among those in the “average” risk group.
Significant reduction in the population burden of CVD can occur only from a “population approach”,
shifting the entire population distribution to lower levels.
9

10. Relationship Between LDL‐C Levels
and Event Rates in Statin Trials
Event (%)
25
LIPID
5
TNT (atorvastatin 80 mg/d)
90
TNT=Treating to New Targets; HPS=Heart Protection Study
CARE=Cholesterol and Recurrent Events Trial
LIPID=Long‐term Intervention with Pravastatin in Ischemic Disease
4S=Scandanavian Simvastatin Survival Study
170
Source: NLEC (National Lipid Education Council
10

11. We Know Statins Work.
What’s The Challenge?
Medication Adherence
“The degree to which the person’s
behavior corresponds with the
agreed recommendations from a
health care provider.”
– World Health Organization
11

12. 12

13. Medication Adherence
22% of U.S. patients take less of the medication than is prescribed
American Heart Association: Statistics you need to know.
http://www.americanheart.org/presenter.jhtml?identifier=107
Accessed November 21, 2007.
13

14. Statin Adherence After 2 Years By
Condition
Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy
in elderly patients with and without acute coronary syndromes.
JAMA 2002;288:462‐467
14

15. But Does it Matter? Would Anything
Get Better with More Adherence?
Results of failure to adhere to
prescribed medications:
Increased hospitalization
Poor health outcomes
Increased costs
Decreased quality of life
Patient death
-60% RR
Dudl, R.J., Wang, M.C., Wong, M., & Bellows, J. (2009)
Preventing Myocardial Infarction and Stroke With a
Simplified Bundle of Cardioprotective Medications.
American Journal of Managed Care
15

16. Impact of Improved Adherence
“Increasing the effectiveness of adherence
interventions is likely to have a far
greater impact on population health…
than any improvement in medical
treatments, including highly promising
advances in biomedical technology”.
–World Health Organization (WHO) report,
Adherence to Long‐Term Therapies: Evidence for Action. 2003
16

17. Medication Adherence: Complex
Behavior With Many Barriers
Patient
Provider
Healthcare
System
PATIENT CAUSES FOR NON ADHERENCE
Complex therapies
Side effects
Failure to understand the need for
the medication
High out‐of‐pocket costs
Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J.
Ref: Osterberg, NEJM, 2005
Long‐term persistence in use of statin therapy in elderly patients.
JAMA 2002;288:455‐461
17

18. Evidence‐Based Strategies for
Improving Statin Adherence
Effective Interventions
Patient
reinforcement
and
reminding
Patient
information
and
education
Simplification
of drug
regimen
Reminding patients seems the most
promising intervention to increase
adherence to lipid lowering drugs.
Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication.
Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004371. DOI:
10.1002/14651858.CD004371.pub3
18

19. Southern California Kaiser Statin
Adherence Program
Objectives
Initial Steps
• Interactive yet cost effective
• Literature review
– If interaction is needed, it has to • Survey target population
be mostly automated
• Develop IVR messaging in
• Sustainable and scalable to all
collaboration with Silverlink:
of Kaiser Southern California
– PDCA cycles to improve the
• Universally applicable
‘listen’ rate
– Computer & reading literacy
– Cultural & language sensitive
– Individualized communications
– Address barriers to adherence
• Increase adherence and
improve clinical outcomes
19

20. Southern California Kaiser Statin
Adherence Program
Personalized
Outreach
To easily switch to
the convenience of
mail order
Integrated
Customer
Service
IVR
Reminder
Calls
Barrier
Survey
To reach & engage the
healthcare consumer
Educational
Materials
To reinforce the
importance of
adherence to statins
To identify causes
of non adherence
20

21. Statin Adherence Program
Evolution
Identify
Issue
Survey For
Barriers
Phase I
Test
Intervention
Launch
Program &
Analyze
Phase II
Scale
Integrate
Segment …
Future
21

22. Statin Adherence Program Details
•
Target:
Patients taking statins
Diabetes or cardiovascular disease
Filled 100‐day prescription
120‐140 days since last fill
•
Timeline:
December 2007 to November 2008 (program)
March 2008 to August 2008 (claims)
•
Location:
Riverside Medical Center in S. California
•
Communications Strategy:
Interactive automated phone calls
Personalized and HIPAA‐compliant messages
Educational and barrier‐breaking messaging
•
Policies:
Calls 10AM‐12PM (Medicare); 7‐8:30PM (Com)
3 attempts on 3 different days; answering
machine messages left
22

23. An Emphasis on Messaging
•
Messaging:
Educational messages on the importance of statin medication as a life‐long medication
Question about intent to refill
Options to hear about a convenient way to refill their medications (mail order)
Questions to determine the personal barriers to adherence for those who reported that they
were unsure or did not intend to refill
– Suggestions around how to address personal barriers
–
–
–
–
•
Improvements and Changes Implemented:
–
–
–
–
–
–
Initially offered a transfer to a KP Pharmacist
Shortened the dialog to improve the engagement rate
Simplified the educational messaging to address health literacy
Changed the targeting from new users to focus on gaps‐in‐care
Added messaging to set expectations – “this will only take a minute or two”
Added a barrier survey with succinct suggestions to address some of the barriers
23

24. Kaiser Statin Adherence Calls
Education & personalization
Barrier Survey
Mail order option
24

25. Statin Adherence Program Analysis
& Results
1000
900
800
700
600
500
400
300
200
100
0
88% Reachable
71% Heard
Target Population
Reachable Population Population That Heard
Message
25

26. The Impact of Targeted
Communications on Adherence
Note: Analysis was based on claims filled within 3 weeks of final outbound call attempt.
26

27. The Power of Barrier Breaking
Messaging
27% of those who stated they had not intended to refill, did refill
their medication after listening to barrier‐breaking messages
DID NOT KNOW
COST
1-2-3
CONVENIENCE
PROVIDER
SIDE EFFECTS
27

28. Population Insights
Key Barriers to Statin Adherence
Cost
11%
Physician
Instructions
15%
Did Not
Know To
Refill
37%
• 13% of those with side effects
eventually refilled
• 42% of those with convenience
issues eventually refilled
Convenience
15%
Side Effects
22%
N=233
Source: Kaiser Silverlink
Statin Adherence Barrier Survey
28

29. A Win‐Win: Mail Order Improves
Adherence
84.7% of patients who received their medications by
mail at least two‐thirds of the time stuck to their
physician‐prescribed regimen, versus 76.9% who
picked up their medications at “brick and mortar”
Duru, O.K & Schmittdiel, J.A. (2010)
Mail Order Pharmacy Use and Adherence to Diabetes‐Related Medications
American Journal of Managed Care
29

30. IVR Technology Supports Statin
Adherence Program
Scalable
Efficient
Personalized
Effective
Automated
Interactive
Calls
Challenge: How to blend reminders with pharmacy counseling in a predictable
way that leveraged research into motivational interviewing and health literacy.
30

31. Data‐Driven Opportunities
Risk
Predictors
Preferences
One campaign with
many different
experiences:
‐Different channel
‐ Different “voice”
‐Different messaging
‐Different timing
‐Different sequencing
Behavioral
Segments
Past
Behavior
31

32. Adaptive Control: Iterative Process
for Optimal Results
•
42%
•
•
56%
49%
Launch segment‐by‐segment
interventions
Assess and measure success
rates and identify segment
‘champions’
Launch ‘challengers’ against
segments
– Consistent process
– Rapid experimentation
– Randomized control group
•
Integrate learning into database
for continual improvement
32

33. Future
• Continue to incorporate ‘learnings’ around
barriers
• Better integration with pharmacy resources
• Scale beyond Statins
• Multi‐channel and multi‐touch strategies
• Auto refill programs
• Segmentation and custom messaging by
segment
33