A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study

Implementation of a multicomponent medication adherence promotion system is associated with a decrease in late T-cell-mediated rejection

Poor immunosuppression adherence in pediatric recipients of liver transplant (LT) contributes to late T-cell-mediated rejection (TCMR) in ~90% of cases and increases the risk of mortality. A medication adherence promotion system (MAPS) was found to reduce late rejection in pediatric recipients of kidney transplants. Using quality improvement methodology, we adapted and implemented the MAPS in our LT clinic. Our primary outcome was population-level rates of late TCMR, measured as a monthly incident rate. Three-hundred fourteen patients undergoing LT are currently cared for at our institution. One-hundred sixty-two (52%) are females with a median age of 16 years and a median age at LT of 2 years. Preimplementation, monthly rejection rates were 0.84 rejections per 100 patient-months. After iterative implementation of MAPS over 2.3 years, monthly rejection rates decreased to 0.46 rejections per 100 patient-months, a 45% decrease in late TCMR. Implementation of MAPS was associated with a sustained 45% decrease in TCMR at a single center, suggesting that quality improvement tools may help improve clinical outcomes. MAPS may be an important tool to ensure long-term allograft health. Future studies should rigorously test MAPS across a multicenter sample.

A 6-month, prospective, randomized controlled trial of customized adherence enhancement versus a bipolar-specific educational control in poorly adherent adolescents and young adults living with bipolar disorder

OBJECTIVE

Few studies have addressed medication adherence in adolescents and young adults (AYAs) with bipolar disorder (BD). This 6-month prospective randomized-controlled trial (RCT) tested customized adherence enhancement for adolescents and young adults (CAE-AYA), a behavioral intervention for AYAs versus enhanced treatment as usual (ETAU).

METHODS

Inclusion criteria were AYAs age 13-21 with BD type I or II with suboptimal adherence defined as missing ≥20% of medications. Assessments were conducted at Screening, Baseline, and weeks 8, 12 and 24. Primary outcome was past 7 day self-reported Tablets Routine Questionnaire (TRQ) validated by electronic pillbox monitoring (SimpleMed). Symptom measures included the Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS).

RESULTS

The mean sample age (N = 36) was 19.1 years (SD = 2.0); 66.7% (N = 24) female, BD Type I (81%). The mean missed medication on TRQ for the total sample was 35.4% (SD = 28.8) at screening and 30.4% (SD = 30.5) at baseline. Both CAE-AYA and ETAU improved on TRQ from screening to baseline. Baseline mean missed medication using SimpleMed was 51.6% (SD = 38.5). Baseline HAM-D and YMRS means were 7.1 (SD = 4.7) and 6.0 (SD = 7.3), respectively. Attrition rate at week 24 was 36%. Baseline to 24-week change on TRQ, adjusting for age, gender, educational level, living situation, family history, race, and ethnicity, showed improvement favoring CAE-AYA versus ETAU of 15%. SimpleMed interpretation was limited due to substantial missing data. There was a significant reduction in depression favoring CAE-AYA.

CONCLUSIONS

CAE-AYA may improve adherence in AYAs with BD, although conclusions need to be made cautiously given study limitations.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT04348604.

International Variability of Barriers to Adherence to Immunosuppressive Medication in Adult Heart Transplant Recipients. A Secondary Data Analysis of the BRIGHT Study

Non-adherence to immunosuppressive medication among transplant patients is associated with poor clinical outcomes and higher economic costs. Barriers to immunosuppressives are a proximal determinant of non-adherence. So far, international variability of barriers to adherence in transplantation has not been studied. As part of the cross-sectional multi-country and multi-center BRIGHT study, barriers to adherence were measured in 1,382 adult heart transplant recipients of 11 countries using the 28-item self-report questionnaire "Identifying Medication Adherence Barriers" (IMAB). Barriers were ranked by their frequency of occurrence for the total sample and by country. Countries were also ranked the by recipients' total number of barriers. Intra-class correlations were calculated at country and center level. The five most frequently mentioned barriers were sleepiness (27.1%), being away from home (25.2%), forgetfulness (24.5%), interruptions to daily routine (23.6%) and being busy (22.8%), fairly consistently across countries. The participants reported on average three barriers, ranging from zero up to 22 barriers. The majority of the variability among reported barriers frequency was situated at the recipient level (94.8%). We found limited international variability in primarily person-level barriers in our study. Understanding of barriers in variable contexts guides intervention development to support adherence to the immunosuppressive regimen in real-world settings.

The SElf-Care After REnal Transplantation Study: A Retrospective Evaluation of a Home-Monitoring Program Implemented as Standard Care

After transplantation self-management is essential for graft survival and optimal quality of life. To address the need for home-based support in self-management, we implemented the "SelfCare after Renal Transplantation" (SeCReT) box, containing home-monitoring equipment combined with a smartphone application that was linked to the electronic patient records. This study investigated the uptake and continuation, protocol adherence, and subjective evaluation of this home-monitoring program. All "de novo" kidney recipients who received the SeCReT-box in the study period (Aug 2021-Dec 2022) were eligible for inclusion. Protocol adherence was defined as ≥75%. Subjective evaluation was assessed with a 5-item questionnaire. Of the 297 recipients transplanted, 178 participants (60%) were included in the analysis. Protocol adherence was 83%, 73%, 66%, and 57% respectively at 5, 10, 20, and 40 weeks of the protocol. With regard to continuation, 135 participants were still in the program at the end of the study period (75% retention rate). Regarding subjective evaluations, 82% evaluated the program positively, and 52% reported lower care needs due to home-monitoring. Results are positive among those who entered and continued the program. Qualitative research is needed on barriers to entering the program and facilitators of use in order to promote optimal implementation.

Electronic health record-enabled routine assessment of medication adherence after solid organ transplantation: the time is now

Medication nonadherence after solid organ transplantation is recognized as an important impediment to long-term graft survival. Yet, assessment of adherence is often not part of routine care. In this Personal Viewpoint, we call for the transplant community to consider implementing a systematic process to screen and assess medication adherence. We believe acceptable tools are available to support integrating adherence assessments into the electronic health record. Creating a standard assessment can be done efficiently and cost-effectively if we come together as a community. More importantly, such monitoring can improve outcomes and strengthen provider-patient relationships. We further discuss the practical challenges and potential rebuttals to our position.

Medication adherence in pediatric kidney transplantation: How to build a bridge over troubled water

Adhering to the immunosuppressive regimen remains one of the biggest challenges for children and adolescents after kidney transplantation. The first paper on nonadherence, co-authored by Dr. Fine, appeared in Pubmed over 45 years ago. Since then, many clinicians and researchers tried to better understand nonadherence and are looking for effective ways to support young people in implementing the complex medication regimen in their daily lives. As a tribute to Dr. Fine, we conducted a comprehensive review providing an overview of adherence-enhancing interventions in the field of pediatric kidney transplantation, thereby focusing on strategies that not only are effective but can also be embedded in daily clinical practice successfully and sustainably. This overview is preceded by a discussion about how to find out who is in need of supportive interventions. We will also argue that interventions should already start before pediatric kidney transplantation and discuss how to decide whether or not a young patient with nonadherence-induced graft loss should undergo retransplantation. We hope this comprehensive overview will rekindle the hope that we can finally turn the tide and beat one of pediatric kidney transplantation's main enemies.

Telemedicine for Kidney Transplant Recipients: Current State, Advantages, and Barriers

Telemedicine is defined as the use of electronic information and communication technologies to provide and support healthcare at a distance. In kidney transplantation, telemedicine is limited but is expected to grow markedly in the coming y. Current experience shows that it is possible to provide transplant care at a distance, with benefits for patients like reduced travel time and costs, better adherence to medication and appointment visits, more self-sufficiency, and more reliable blood pressure values. However, multiple barriers in different areas need to be overcome for successful implementation, such as recipients' preferences, willingness, skills, and digital literacy. Moreover, in many countries, limited digital infrastructure, legislation, local policy, costs, and reimbursement issues could be barriers to the implementation of telemedicine. Finally, telemedicine changes the way transplant professionals provide care, and this transition needs time, training, willingness, and acceptance. This review discusses the current state and benefits of telemedicine in kidney transplantation, with the aforementioned barriers, and provides an overview of future directions on telemedicine in kidney transplantation.

Implementing a self-reported immunosuppression adherence questionnaire to screen for non-adherence in routine care of kidney transplant recipients

INTRODUCTION

Self-reported measures of immunosuppression adherence have been largely examined in research settings.

METHODS

In this single center study of 610 kidney transplant recipients, we examined if a voluntary, non-anonymous self-report measure could identify non-adherence in a routine clinic setting and how patients perceived such a measure. Non-adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) and patient perception was elicited using a customized questionnaire.

RESULTS

Non-responders to the survey (15%) were younger, more likely to be black, and less likely to have had a pre-emptive transplant. Among complete responders (n = 485), 38% reported non-adherence with non-adherent patients being younger (54 y vs. 60 y; p = .01), less likely to have been on dialysis pre-transplant (59% vs. 68%; p = .04), further out from transplant (37 vs. 22 months; p < .001) and had more rejections in the preceding year (8% vs. 3%; p = .02). Self-reported non-adherence was associated with higher calcineurin inhibitor intra-patient variability (27.4% vs. 24.5%; p = .02), but not with donor-specific antibody detection (27.8% vs. 21.2%, p = .15). Of patients providing feedback (n = 500), the majority of patients felt comfortable reporting adherence (92%), that the survey was relevant to their visit (71%), and that the survey did not interfere with their clinic visit (88%).

CONCLUSION

In summary, a self-reported questionnaire during clinic visits identified immunosuppression non-adherence in a significant proportion of patients and was well received by patients. Integrating self-report measures into routine post-transplant care may enable early identification of non-adherence.

Is Non-Adherence Associated with Adverse Outcomes in Kidney Transplant Recipients? The Role of Non-Adherence as a Risk and Predictor Factor for Graft Loss and Death

Introduction

 Non-adherence in kidney transplants is diversely defined. Immunosuppression non-adherence (INA) is the most used definition and has been associated with graft loss and acute rejection. But INA assesses only one fraction of adherence. Therefore, we analyzed the association of a holistic non-adherence definition with transplant outcomes and compared its prediction performance with other definitions.

Methods

 We retrospectively included 739 kidney recipients between 2019 and 2021. We evaluated holistic non-adherence (HNA), suboptimal-immunosuppressor levels (SIL), appointment non-adherence (ANA), procedure non-adherence (PNA) and INA. The main outcomes were graft loss, graft rejection, and mortality. A backward logistic regression was performed estimating adjusted and un-adjusted odds ratio (OR) for each outcome. Finally, we compared the non-adherence definitions' prediction for the main outcomes using the area under the curve.

Results

HNA was present in 28.7% of patients. Non-adherent patients had an adjusted OR of 2.66 (1.37-5.15) for mortality, 6.44 for graft loss (2.71-16.6), and 2.28 (1.15-4.47) for graft rejection. INA and PNA presented a moderate discrimination for graft loss and HNA and ANA mild-to-moderate discrimination for graft loss and death.

Conclusion

Holistic non-adherence was associated with worst outcomes in kidney recipients and had a significant prediction performance for graft loss and mortality.

Prevalence and Modifiable Factors for Holistic Non-Adherence in Renal Transplant Patients: A Cross-Sectional Study

Introduction

In renal transplant recipients, compliance with medical therapy is vital. Non-adherence is considered a risk factor for worst outcomes in kidney recipients, with attributed outcomes of 64% for graft loss and 80% for late acute rejection. Most literature defines adherence as self-based immunosuppression compliance but does not consider other relevant factors such as consult and procedure compliance. Therefore, this study aims to describe adherence prevalence in kidney transplant recipients and the factors related to non-adherence.

Methods

This cross-sectional study included 1030 renal transplant patients followed by Colombiana de Trasplantes between January 2019 and July 2021. Sociodemographic and clinical variables were obtained based on clinical records. The mental-health group diagnosed holistic adherence in a semi-structured interview. The diagnosis considered medication intake failure, frequency and number of failures to medical controls or other procedures, suspicious non-adherence behaviors, and serum levels of immunosuppressants. A bivariate followed a descriptive analysis, and a forward logistic regression was performed for non-adherence.

Results

Patients had a median of 47 years, and 58.1% were male. Non-adherence was presented in 30.7% of patients. The non-adherence patients were younger, with a higher prevalence of males, single, divided transplant care, had a longer time after transplantation, psychopathological diagnosis, and more reinforcement education by only nursing. Older age and multidisciplinary reinforcement education were protective factors. On the other hand, poor social support, psychopathology diagnosis, and longer time after transplant presented as non-adherence risk factors.

Conclusion

Holistic non-adherence was diagnosed in approximately one-third of renal transplant recipients. Its definition included more than just medication non-compliance and could identify more non-adherent patients. Notably, there is a need to consider the related factors in the health follow-up and encourage future research in modifiable factor interventions aiming to increase adherence and achieve better outcomes for renal transplant patients.

The Barriers Assessment Tool-A Patient-Centered Measure of Adherence Barriers in Pediatric Kidney Transplantation

OBJECTIVE

Assessing barriers to adherence provides helpful information to clinicians. The objective of this study was to describe the clinical utility of the Barriers Assessment Tool (BAT) using clinical data for a large, midwestern U.S. pediatric kidney transplant program.

METHODS

Focus group and clinical data were obtained during post-transplant medical visits. Qualitative and quantitative assessment methods were utilized to describe patient and caregiver feedback on the BAT, clinical utility, concordance between reporters, and the effect of interventions on subsequent assessment and electronically measured adherence.

RESULTS

Patients were willing to discuss adherence issues with their care team. There was substantial agreement between patients and caregivers at two timepoints. If a barrier was not addressed, 89.6% (43/48) of patients and 85.9% (67/78) of caregivers reported the same BAT scores from the first to second assessment. When barriers were addressed with a clinic-based intervention, 82% of caregivers reported no adherence barriers. No significant change was found for patient-reported barriers.

CONCLUSIONS

Standardized assessment of barriers to medication adherence provides actionable information to clinicians. Standardized assessment of adherence barriers may give clinicians opportunities to help patients and caregivers overcome these barriers which can decrease risk of rejection.

Adaptation Process After Kidney Transplantation in Older Adult Recipients: Applied Grounded Theory

Despite the increase in older adults receiving kidney transplantation (KT), little is known about their experience and adaptation process after KT. The current study aimed to explore the process of adaptation after KT in older adult recipients using a qualitative design and grounded theory methodology. Sixteen recipients who had KT at age ≥60 years and received follow-up care were recruited at a university hospital in South Korea. Data were collected from July to December 2017 through in-depth interviews with individual participants. The core theme of the adaptation process after KT in older adult recipients was A Journey of Straining to Save the Last Lifeline. The adaptation process comprised three stages: confusion, depression, and compromise. Tailored interventions based on the in-depth understanding of the adaptation process found in the current study are needed to improve adaptation after KT in older adult recipients. [Research in Gerontological Nursing, 16(4), 183-193.].

Kidney-transplanted Adolescents-Nonadherence and Graft Outcomes During the Transition Phase: A Nationwide Analysis, 2000-2020

BACKGROUND

The transition from pediatric to young adult care is a vulnerable period for the renal transplant patient. We aimed to identify medication nonadherence (noninitiation, nonimplementation, and nonpersistence) and graft loss rates among adolescents and young adults and elucidate the influence of the transition phase on transplant outcomes.

METHODS

A retrospective nationwide cohort analysis of all renal transplantations in Norway from 2000 to 2020 was performed. Data were retrieved from the Norwegian Renal Registry, and adherence data from hospital charts. Patients transplanted aged <50 y, with functioning graft at 6 mo, were included. Recipients transplanted aged <26 y were compared with recipients transplanted aged 26-50 y. Graft loss, acute rejection, and development of de novo donor-specific antibodies were assessed in relation to the transition phase, defined as 14-26 y.

RESULTS

Data from 1830 kidney recipients were included: 371 (20%) transplanted <26 y (64% male, 68% living donor) versus 1459 transplanted 26-50 y (63% male, 44% living donor). There were 298 graft losses, 78 (21%) in the <26-y group versus 220 (15%) in the 26- to 50-y group. During the transition phase, 36 grafts were lost, 29 (81%) after transfer to the adult service. Medication nonadherence was the reason for 58% (21 of 36) of the losses during the transition phase, versus 12% (27 of 220) in the 26- to 50-y group ( P < 0.001). The 5-y graft survival rate was 89% (95% confidence interval, 85%-92%) and 94% (92%-95%), respectively ( P = 0.01).

CONCLUSIONS

Nonadherence was verified as the main cause of kidney graft loss in the transition phase.

The learning health system for pediatric nephrology: building better systems to improve health

Learning health systems (LHS) align science, informatics, incentives, and culture for continuous improvement and innovation. In this organizational system, best practices are seamlessly embedded in the delivery process, and new knowledge is captured as an integral byproduct of the care delivery experience aimed to transform clinical practice and improve patient outcomes. The objective of this review is to describe how building better health systems that integrate clinical care, improvement, and research as part of an LHS can improve care within pediatric nephrology. This review will provide real-world examples of how this system can be established in a single center and across multiple centers as learning health networks.

A Cost-effectiveness Analysis of Adherence Promotion Strategies to Improve Rejection Rates in Adolescent Kidney Transplant Recipients

RATIONALE & OBJECTIVE

Nonadherence to medical regimens increases the risk of graft loss among adolescent and young adult recipients of kidney transplants. Interventions that improve adherence may decrease rejection rates, but their perceived costs are a barrier to clinical implementation. We developed a model to assess the cost-effectiveness of an adherence promotion strategy, the Medication Adherence Promotion System (MAPS).

STUDY DESIGN

Simulation-based. Data sources included published articles indexed in Medline or referenced in bibliographies of relevant English-language articles. Data on costs and outcomes were taken from a single clinical center.

SETTING & POPULATION

US adolescent patients after their first kidney transplant.

INTERVENTION

Usual posttransplant care versus usual care plus MAPS.

OUTCOME

Effectiveness measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars.

MODEL, PERSPECTIVE, & TIMEFRAME

Markov state transition decision model. We used a health care system perspective with a lifelong time horizon.

RESULTS

In the base-case analysis, MAPS was more effective and less costly than usual care. MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Extending results to a program level with 100 patients, any adherence promotion intervention similar in effectiveness to MAPS would cost less than $50,000/QALY if the start-up costs were <$2.5 million and annual costs <$188,000. Strategies with costs similar to MAPS that reduce the risk of rejection by as little as 3% would also have similar cost-effectiveness.

LIMITATIONS

Estimates of components and costs for MAPS were based on a single center.

CONCLUSIONS

Adherence promotion strategies with costs similar to MAPS can be cost-effective as long as they reduce rejection rates by at least 3%. This model can be applied to study the cost-effectiveness of adherence promotion strategies with varying costs and outcomes.