Black Creek CHC - Ontario Lung Association

Electronically‐Assisted Health Coaching: Bringing Health to Everyone
Paul Ritvo. PhD. Associate Professor
Noah Wayne, PhD (Cand.)
School of Kinesiology & Health Science
York University
COPD / Diabetes / CVD
• Inflammation & oxidative stress
• Symptomatic severity exacerbated by psychological distress & lifestyle choice
• Opportunity for self healing: stress reduction, improved diet & exercise • Reduction &/or reversal of diagnostic criteria & symptom array
Recent History
2005 ‐ first Apple store in Canada (Yorkdale Mall)
2007‐ first Apple iPhone appears
2007 ‐ first iTunes Music Store in Canada
Original Apple Computer in 1976
Meteoric Rise
Year
Net Sales
Net Profits
Revenue Growth
Return on Net Sales
2004
8,279
266
33%
3%
2005
13,931
1,328
68%
10%
2006
19,315
1,989
39%
10%
2007
24,578
3, 495
27%
14%
2008
37, 491
6,119
53%
16%
2009
42,905
8,235
14%
19%
2010
65,225
14,031
52%
21%
Net Sales increase of 800% between 2004 and 2010
What was Jobs vision ?
A personal computer
&/or smartphone
for everyone …..
What was Jobs vision ?
A personal computer
&/or smartphone
for everyone…..
Can there be health benefits?
Lester, Ritvo, Mills et al., 2010 (Lancet)
N = 400 pts. - viral suppression in 75.4% of SMS group
vs. 66.3% of controls (p=0.047).
ITT analysis: 57.1% vs. 48.3% patients in SMS vs. controls
suppressed viral load at 12 months (p=0.040)
Each Monday morning, a site-clinician (nurse) sent a
text message (SMS) : Mambo?
How are you?
Lester, Ritvo, Mills et al., 2010 (costs)
• Inexpensive intervention due to…..
patient engagement
• Weekly SMS costs = 5 cents
• $20 /100 patients/month
• Follow-up calls averaged $3.75/nurse/month (130 pts
per nurse)
(Arpin-Cribbie, Irvine & Ritvo, 2012)
Perfectionistic participants (n=77) randomized to web‐based intervention vs. no treatment
Web‐based CBT = perfectionism, depression, anxiety
(Arpin-Cribbie, Irvine & Ritvo, 2012)
Perfectionistic participants (n=77) randomized to web‐based intervention vs. no treatment
Web‐based CBT = perfectionism, depression, anxiety
Cost = $ 0
(Radhu, Daskalakis, Guglietti, Farzan, Barr,
Arpin-Cribbie, Fitzgerald, Ritvo, 2012 )
•
•
•
•
N = 47 perfectionists randomly assigned to 12‐weeks CBT vs. wait list control
Web‐based intervention Significant decreases in anxiety sensitivity & negative automatic thoughts
CBT intervention group demonstrated significantly longer Cortical Silent Period vs. wait list controls
Evaluating a Web‐based cognitive‐behavioural therapy for maladaptive perfectionism in university students, Radhu, Daskalakis, Guglietti, Farzan, Barr, Arpin‐Cribbie, Irvine & Ritvo, Journal of American College Health, 2012
Cost = $ 0
Cortical Silent Period Results
40
Intervention) inCSP(milliseconds)
MeanChange (Post-Intervention- Pre-
35
30
25
20
15
10
5
0
CBT
Wait List Control
-5
Group
Figure 2. Mean change in cortical silent period (CSP) duration in 7 participants in the treatment group and 8 participants in the control group. Values represent ± SEM. Study 2: Mindfulness
y N = 58
y Experienced meditators (n = 20)
y 3 – 7 hours of meditation per week for >2 yrs
y Novice meditators (n = 18)
y 12 week meditation course &/or < 2 yrs practice
y Healthy controls (n = 20)
– No meditation experience
– Age and Sex matched to meditators
CSP Pre ‐ Post Meditation by Group
0.155
0.15
Time (sec)
0.145
0.14
Non-Meditator
Novice
0.135
Experienced
0.13
0.125
*
0.12
Pre CSP
Post CSP
Time
EEG ‐ Frontal Alpha Power
1.09
Meditator
Non‐Meditator
Average Alpha Power
1.08
1.07
1.06
1.05
1.04
*
0
*
15
*
30
Minutes
45
Frontal Alpha Power
• Meditators show significantly more alpha than non‐meditators – F(1, 58) = 5.31, p = 0.03
• Alpha changes over course of meditation
• From baseline to 15 min (p =0.02)
• From baseline to 30 min (p = 0.01)
• Significant decrease from 30 to 45 min (p=0.04)
Evoked Gamma During N‐back Memory Task
2 ‐ back
3 – back
99.8
99.6
Mea Evoked Gamma Power
99.4
Meditators
99.2
99
*
98.8
98.6
Healthy Controls
98.4
98.2
2‐back
3‐back
N‐back Condition
* Signifies significant difference between Meditators & Non‐Meditators
% Correct Responses during N‐back
100
3 ‐ back
2 ‐back
Mean Coorect Response (%)
95
90
Meditators
85
*
80
Healthy Controls
75
70
65
2‐back
3‐back
N‐back Condition
* Significant difference
Mindfulness: A New Approach to Reduce COPD Hospitalizations
Pts. with severe lung disease who underwent lung surgery & mindfulness meditation training before surgery reduced their hospital stay by 3 days (Benzo et al. 2011) Qualitative analyses suggest MM might reduce hospital admissions by 20% in COPD; 70% of COPD costs are due to hospitalization
Triple Win:
– How to execute ?
Improved health in chronic disease Prevention of worsening disease
Prevention of disease Reduced cost
Increased employment Yfile.news.yorku.ca/2012/09/12/feds‐announce‐Millions‐for‐
new‐project‐York‐a‐major‐partner/
The Connected Health and Wellness Project is a collaboration led by York University, NexJ Systems and McMaster University ….cloud based software supports patients in accessing and sharing health records with family, friends and care teams, including a health coach, who collaboratively manages health and wellness. The profession of health coaches is being developed at York University.
HealthCoach Tool –
Connected Wellness Platform
• $15 million contract from FedDev Canada
• Developed by NexJ Systems (Industry Partner)
• Mobile intervention platform for chronic disease prevention
– Smartphone application (iPhone, Android, Blackberry)
– Web application (views for patient + health coach)
Health Coach Program Evolution
Black Creek CHC (Pilot study)
Participants: N= 13
Status: Complete
Outcome: Software – hardware developed
Application & Testing of Software now at 4 sites
1 ‐ North York Family Health Team
Study Design: RCT
3 – Southlake RHC
Study Design: Single arm trial
Participants: N= 65, RCT
Status: Active
2 ‐ Healthy Student Initiative
Study Design: RCT
Participants: N = 120
Status: Active
4 ‐ Black Creek CHC Supported by: Public Health Agency of Canada
Study Design: RCT
Participants: N= 120, T2DM
Status: Prestudy Preparation
Healthy Student Initiative
(Ritvo et al., 2014)
Mindfulness Meditation Tutorials over 2 Semesters
Healthy Student Initiative
(Ritvo et al., 2014)
Mindfulness Meditation Tutorials over 2 Semesters
How does this apply to COPD?
Mindfulness for COPD ‐ Session 1
https://www.youtube.com/watch?v=rZ2ka_3AdoM
Mindfulness for COPD ‐ Session 2
https://www.youtube.com/watch?v=kVqApRCTAXw
Mindfulness for COPD ‐ Session 3
https://www.youtube.com/watch?v=QP92o‐BFEr8
Dual Process Model
• Reflective (C‐System) (more Cortical)
•
•
•
•
•
Controlled processes
Slow operating
Fast learning
Phylogenetically newer
Higher order processing ‐
abstract concepts
• Reflexic (X‐System)
(more Limbic)
•
•
•
•
•
Automatic processes
Fast operating
Slow learning
Phylogenetically older
Lower order processing Satpute & Liberman, 2006
Critical Balance in Adherence
Pre‐frontal cortex: executive function
Limbic System: pursue gratification
‘Do what is rational’
‘Do what is gratifying’
Adherence
Pre‐frontal cortex ‐
executive function
‘Do what is rational’
>
Limbic System – pursue gratification
‘Do what is gratifying’
Non‐Adherence
Limbic System –
pursue gratification
‘Do what is gratifying’
>
Pre‐frontal cortex ‐
executive function
‘Do what is rational’
Impulsive Behaviours
Mindfulness Effect
More addictable…..
GABA system mediates Dopamine Greater stress…
Neuro‐inhibition increases attention; decreases stress reactivity
More sensation‐
seeking…
Rational risk‐taking
Emotional conflict…
Resolution of cognitive‐emotional conflict
Why is exercise good for people with COPD?
It helps you take control
It helps you maintain independence. The more you exercise regularly, the easier your activities ‐ like shopping, cooking & cleaning
It keeps you out of hospital….exercise improves your general well‐
being while keeping you healthy ‐ & at home
It helps you maintain weight… excess fat around the stomach presses on the diaphragm, making it harder to breathe Exercise stops the vicious spira; of inactivity, enabling easier breathing It can improve sleep Exercise Education Program
34
Pilot Study (BCCHC)
Wayne, Ritvo, et al., 2014
Model Participant
• Baseline HbA1C = 8.5%
• 3 month HbA1C = 7.0% ‐ Reduction of 1.5%
• Physician decreased daily dose of Diamicron
from 60mg ‐> 30mg in Response to lower glucose levels
Blood Glucose – Daily View
June 8 – June 18
Blood Glucose – Daily View
October 23 – October 30
Blood Glucose – Weekly AVG
June – Oct Radical reduction by week 4 results in physician reduction of Diamicron
dose Regulation then under more behavioural control Exercise & Blood Glucose – Daily View
August 29 – September 26
Exercise increases to several sessions/ wk. Death in
family results in 3‐day
exercise gap
& glucose
spike, followed by resumption & reduction
Exercise & Blood Glucose – Weekly AVG
June – October
Exercise varies between walking & use of treadmill & resistance. By week 10, another significant glucose drop & improved stabilization
Food View
October 16‐19
Food pictures reflect healthier choices
Close up of Food
*Note: absence of simple carbohydrates &
introduction of salad
Scaling Up
Grad Student & Health Coach Training
Primary Care
Exercise Room & Mall Walking
Websites:
‐ Inform
‐ Track
‐ Share
Ontarioonthemove.ca
Onthemind.ca
Electronic
Generation
Research &
Feedback
Volunteers
Text Messages
Smart phone
Software
Remote Monitoring
• Custom designed website focused on exercise • Database of ‘how‐to’ and ‘where to’ for various exercise activities
• Personal tracking of exercise activity
• Exercise specialist guidance – consultation
• Social networking with other exercisers
• Networking groups for running, biking, etc.
www.ontarioonthemove.ca
www.ontarioonthemove.ca
Activity Logging System
– Allows user to track their own progress with customized workout routines
– Support clinicians in:
•
•
•
•
Tracking/rewarding patient progress
Send reminder ‐ support messages (text messaging)
Relevant information sent easily to patients
Capacity to monitor large numbers Onthemind.ca
• Mindfulness meditation website
• 5 minute, 10 minute, 15 minute, 20 minute….recorded audiotapes….instantly accessible (with mouse ‐ click)
• Mindfulness applied to everyday topics
• Electronically led & attended group sessions
https://meet39986714.adobeconnect.com/system/login?
domain=https%3A%2F%2Fmeet39986714.adobeconne
ct.com&next=/&set‐lang=en
Electronic Revolution
•
•
•
•
Turning the exception into norm
Socio‐electronic engagement
Reducing costs with available technologies
Determining the health future ‐ now