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Nishio Lucar AG, Patel A, Mehta S, Yadav A, Doshi M, Urbanski MA, Concepcion BP, Singh N, Sanders ML, Basu A, Harding JL, Rossi A, Adebiyi OO, Samaniego-Picota M, Woodside KJ, Parsons RF. Expanding the access to kidney transplantation: Strategies for kidney transplant programs. Clin Transplant 2024; 38:e15315. [PMID: 38686443 DOI: 10.1111/ctr.15315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.
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Affiliation(s)
- Angie G Nishio Lucar
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Ankita Patel
- Recanati-Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anju Yadav
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan A Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - M Lee Sanders
- Department of Internal Medicine, Division of Nephrology, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Arpita Basu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Oluwafisayo O Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana, USA
| | | | | | - Ronald F Parsons
- Department of Surgery, University of Pennsylvannia, Philadelphia, Pennsylvania, USA
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Hezer B, Massey EK, Reinders ME, Tielen M, van de Wetering J, Hesselink DA, van den Hoogen MW. Telemedicine for Kidney Transplant Recipients: Current State, Advantages, and Barriers. Transplantation 2024; 108:409-420. [PMID: 37264512 PMCID: PMC10798592 DOI: 10.1097/tp.0000000000004660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Bartu Hezer
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Emma K. Massey
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Marlies E.J. Reinders
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Mirjam Tielen
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Jacqueline van de Wetering
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Dennis A. Hesselink
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
| | - Martijn W.F. van den Hoogen
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Internal Medicine, Rotterdam, the Netherlands
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von Itzstein MS, Gwin ME, Gupta A, Gerber DE. Telemedicine and Cancer Clinical Research: Opportunities for Transformation. Cancer J 2024; 30:22-26. [PMID: 38265922 PMCID: PMC10827351 DOI: 10.1097/ppo.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
ABSTRACT Telemedicine represents an established mode of patient care delivery that has and will continue to transform cancer clinical research. Through telemedicine, opportunities exist to improve patient care, enhance access to novel therapies, streamline data collection and monitoring, support communication, and increase trial efficiency. Potential challenges include disparities in technology access and literacy, physical examination performance, biospecimen collection, privacy and security concerns, coverage of services by insurance, and regulatory considerations. Coupled with artificial intelligence, telemedicine may offer ways to reach geographically dispersed candidates for narrowly focused cancer clinical trials, such as those targeting rare genomic subsets. Collaboration among clinical trial staff, clinicians, regulators, professional societies, patients, and their advocates is critical to optimize the benefits of telemedicine for clinical cancer research.
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Affiliation(s)
- Mitchell S. von Itzstein
- Department of Internal Medicine (Division of Hematology-Oncology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary E. Gwin
- Department of Internal Medicine, University of Texas Southwestern Medical Center. Dallas, Texas, USA
| | - Arjun Gupta
- Department of Internal Medicine (Division of Hematology-Oncology), University of Minnesota, Minneapolis, Minnesota, USA
| | - David E. Gerber
- Department of Internal Medicine (Division of Hematology-Oncology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Montgomery A, Tarasovsky G, Izadi Z, Shiboski S, Whooley MA, Dana J, Ehiorobo I, Barton J, Bennett L, Chung L, Reiter K, Wahl E, Subash M, Schmajuk G. An Electronic Dashboard to Improve Dosing of Hydroxychloroquine Within the Veterans Health Care System: Time Series Analysis. JMIR Med Inform 2023; 11:e44455. [PMID: 37171858 PMCID: PMC10221491 DOI: 10.2196/44455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/03/2023] [Accepted: 03/19/2023] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Hydroxychloroquine (HCQ) is commonly used for patients with autoimmune conditions. Long-term use of HCQ can cause retinal toxicity, but this risk can be reduced if high doses are avoided. OBJECTIVE We developed and piloted an electronic health record-based dashboard to improve the safe prescribing of HCQ within the Veterans Health Administration (VHA). We observed pilot facilities over a 1-year period to determine whether they were able to improve the proportion of patients receiving inappropriate doses of HCQ. METHODS Patients receiving HCQ were identified from the VHA corporate data warehouse. Using PowerBI (Microsoft Corp), we constructed a dashboard to display patient identifiers and the most recent HCQ dose and weight (flagged if ≥5.2 mg/kg/day). Six VHA pilot facilities were enlisted to test the dashboard and invited to participate in monthly webinars. We performed an interrupted time series analysis using synthetic controls to assess changes in the proportion of patients receiving HCQ ≥5.2 mg/kg/day between October 2020 and November 2021. RESULTS At the start of the study period, we identified 18,525 total users of HCQ nationwide at 128 facilities in the VHA, including 1365 patients at the 6 pilot facilities. Nationwide, at baseline, 19.8% (3671/18,525) of patients were receiving high doses of HCQ. We observed significant improvements in the proportion of HCQ prescribed at doses ≥5.2 mg/kg/day among pilot facilities after the dashboard was deployed (-0.06; 95% CI -0.08 to -0.04). The difference in the postintervention linear trend for pilot versus synthetic controls was also significant (-0.06; 95% CI -0.08 to -0.05). CONCLUSIONS The use of an electronic health record-based dashboard reduced the proportion of patients receiving higher than recommended doses of HCQ and significantly improved performance at 6 VHA facilities. National roll-out of the dashboard will enable further improvements in the safe prescribing of HCQ.
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Affiliation(s)
- Anna Montgomery
- San Francisco VA Medical Center, San Francisco, CA, United States
| | - Gary Tarasovsky
- San Francisco VA Medical Center, San Francisco, CA, United States
- University of California San Francisco, San Francisco, CA, United States
| | - Zara Izadi
- University of California San Francisco, San Francisco, CA, United States
| | - Stephen Shiboski
- University of California San Francisco, San Francisco, CA, United States
| | - Mary A Whooley
- San Francisco VA Medical Center, San Francisco, CA, United States
- University of California San Francisco, San Francisco, CA, United States
- UCSF Philip R Lee Institute for Health Policy Studies, San Francisco, CA, United States
| | - Jo Dana
- San Francisco VA Medical Center, San Francisco, CA, United States
| | - Iziegbe Ehiorobo
- University of California San Francisco, San Francisco, CA, United States
| | | | - Lori Bennett
- Ralph H Johnson VA Medical Center, Charleston, SC, United States
| | - Lorinda Chung
- Palo Alto VA Medical Center, Palo Alto, CA, United States
- Stanford University, Palo Alto, CA, United States
| | - Kimberly Reiter
- Raymond G Murphy VA Medical Center, Albuquerque, AZ, United States
- University of New Mexico School of Medicine, Albuquerque, AZ, United States
| | - Elizabeth Wahl
- Seattle/Puget Sound VA Healthcare System, Seattle, WA, United States
| | - Meera Subash
- UT Physicians Center for Autoimmunity, Houston, TX, United States
| | - Gabriela Schmajuk
- San Francisco VA Medical Center, San Francisco, CA, United States
- University of California San Francisco, San Francisco, CA, United States
- UCSF Philip R Lee Institute for Health Policy Studies, San Francisco, CA, United States
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van Uden RCAE, Bakker MA, Joosten SGL, Meijer K, van den Bemt PMLA, Becker ML, Vervloet M. Implementation of a Patient Questionnaire in Community Pharmacies to Improve Care for Patients Using Combined Antithrombotic Therapy: A Qualitative Study. PHARMACY 2023; 11:80. [PMID: 37218962 PMCID: PMC10204406 DOI: 10.3390/pharmacy11030080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/12/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
For several indications or combinations of indications the use of more than one antithrombotic agent is required. The duration of combined antithrombotic therapy depends on indication and patient characteristics. This study investigated the use of an antithrombotic questionnaire tool that had been developed for pharmacists to detect patients with possible incorrect combined antithrombotic therapy. The objective of this study was to identify potential barriers and facilitators that could influence the implementation of the developed antithrombotic questionnaire tool in daily community pharmacy practice. A qualitative study was conducted at 10 Dutch community pharmacies in which the antithrombotic questionnaire tool had been used with 82 patients. Semi-structured interviews were conducted with pharmacy staff who used the antithrombotic questionnaire tool. The interview questions to identify barriers and facilitators were based on the Consolidated Framework for Implementation Research. The interview data were analysed using a deductive thematic analysis. Ten staff members from nine different pharmacies were interviewed. Facilitators for implementation were that the questionnaire was easily adaptable and easy to use, as well as the relative short duration to administer the questionnaire. A possible barrier for using the questionnaire was a lower priority for using the questionnaire at moments when the workload was high. The pharmacists estimated that the questionnaire could be used for 70-80% of the patient population and they thought that it was a useful addition to regular medication surveillance. The antithrombotic questionnaire tool can be easily implemented in pharmacy practice. To implement the tool, the focus should be on integrating its use into daily activities. Pharmacists can use this tool in addition to regular medication surveillance to improve medication safety in patients who use combined antithrombotic therapy.
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Affiliation(s)
- Renate C. A. E. van Uden
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Marit A. Bakker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
| | - Stephan G. L. Joosten
- Community Pharmacy BENU Pharmacy Nieuwpoort, Jan van der Heydenweg 352, 3401 RJ IJsselstein, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Matthijs L. Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands
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Bul KCM, Bannon C, Krishnan N, Dunlop A, Szczepura A. Can eHealth applications improve renal transplant outcomes for adolescents and young adults? A systematic review. Transplant Rev (Orlando) 2023; 37:100760. [PMID: 37172527 DOI: 10.1016/j.trre.2023.100760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/20/2023] [Accepted: 04/01/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Adherence to medical treatment following a kidney transplant is particularly challenging during adolescence and young adulthood. There is increasing evidence of the benefits of the use of computer and mobile technology (labelled as eHealth hereafter) including serious gaming and gamification in many clinical areas. We aimed to conduct a systematic review of such interventions designed to improve self-management skills, treatment adherence and clinical outcomes in young kidney transplant recipients aged 16 to 30 years. METHOD The Cochrane Library, MEDLINE, EMBASE, PsychINFO, SCOPUS and CINAHL databases were searched for studies published between 01 January 1990 and 20 October 2020. Articles were short-listed by two independent reviewers based on pre-defined inclusion/exclusion criteria. Reference lists were screened and authors of published conference abstracts contacted. Two reviewers independently appraised selected articles, systematically extracted data and assessed the quality of individual studies (CASP and SORT). Thematic analysis was used for evidence synthesis; quantitative meta-analysis was not possible. RESULTS A total of 1098 unique records were identified. Short-listing identified four eligible studies, all randomized controlled trials (n = 266 participants). Trials mainly focused on mHealth applications or electronic pill dispensers (mostly for patients >18 years old). Most studies reported on clinical outcome measures. All showed improved adherence but there were no differences in the number of rejections. Study quality was low for all four studies. CONCLUSIONS The findings of this review suggest that eHealth interventions can improve treatment adherence and clinical outcomes for young kidney transplant patients. More robust and high-quality studies are now needed to validate these findings. Future studies should also extend beyond short-term outcomes, and consider cost of implementation. The review was registered with PROSPERO (CRD42017062469).
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Affiliation(s)
- Kim C M Bul
- Coventry University, Institute for Health and Wellbeing, Centre for Intelligent Healthcare, West Midlands, Coventry, United Kingdom.
| | - Christopher Bannon
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Nithya Krishnan
- University Hospital Coventry and Warwickshire NHS Trust, Renal, West Midlands, Coventry, United Kingdom
| | - Amber Dunlop
- University Hospital Coventry and Warwickshire NHS Trust, Library & Knowledge Services, West Midlands, Coventry, United Kingdom
| | - Ala Szczepura
- Coventry University, Institute for Health and Wellbeing, Centre for Healthcare and Communities, West Midlands, Coventry, United Kingdom
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Mellon L, Doyle F, Hickey A, Ward KD, de Freitas DG, McCormick PA, O'Connell O, Conlon P. Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients. Cochrane Database Syst Rev 2022; 9:CD012854. [PMID: 36094829 PMCID: PMC9466987 DOI: 10.1002/14651858.cd012854.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy. OBJECTIVES This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results. MAIN RESULTS Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%). There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported. AUTHORS' CONCLUSIONS Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.
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Affiliation(s)
- Lisa Mellon
- Department of Health Psychology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Doyle
- Department of Health Psychology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Anne Hickey
- Department of Health Psychology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Kenneth D Ward
- School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Declan G de Freitas
- Department of Nephrology and Kidney Transplantation, Beaumont Hospital, Dublin, Ireland
| | - P Aiden McCormick
- Irish Liver Transplant Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Oisin O'Connell
- Irish National Lung and Heart Transplant Program, Mater Misericordiae University, Dublin, Ireland
| | - Peter Conlon
- Department of Nephrology and Kidney Transplantation, Beaumont Hospital, Dublin, Ireland
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Lan X, Yu H, Cui L. Application of Telemedicine in COVID-19: A Bibliometric Analysis. Front Public Health 2022; 10:908756. [PMID: 35719666 PMCID: PMC9199898 DOI: 10.3389/fpubh.2022.908756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTelemedicine as a tool that can reduce potential disease spread and fill a gap in healthcare has been increasingly applied during the COVID-19 pandemic. Many studies have summarized telemedicine's technologies or the diseases' applications. However, these studies were reviewed separately. There is a lack of a comprehensive overview of the telemedicine technologies, application areas, and medical service types.ObjectiveWe aimed to investigate the research direction of telemedicine at COVID-19 and to clarify what kind of telemedicine technology is used in what diseases, and what medical services are provided by telemedicine.MethodsPublications addressing telemedicine in COVID-19 were retrieved from the PubMed database. To extract bibliographic information and do a bi-clustering analysis, we used Bicomb and gCLUTO. The co-occurrence networks of diseases, technology, and healthcare services were then constructed and shown using R-studio and the Gephi tool.ResultsWe retrieved 5,224 research papers on telemedicine at COVID-19 distributed among 1460 journals. Most articles were published in the Journal of Medical Internet Research (166/5,224, 3.18%). The United States published the most articles on telemedicine. The research clusters comprised 6 clusters, which refer to mental health, mhealth, cross-infection control, and self-management of diseases. The network analysis revealed a triple relation with diseases, technologies, and health care services with 303 nodes and 5,664 edges. The entity “delivery of health care” was the node with the highest betweenness centrality at 6,787.79, followed by “remote consultation” (4,395.76) and “infection control” (3,700.50).ConclusionsThe results of this study highlight widely use of telemedicine during COVID-19. Most studies relate to the delivery of health care and mental health services. Technologies were primarily via mobile devices to deliver health care, remote consultation, control infection, and contact tracing. The study assists researchers in comprehending the knowledge structure in this sector, enabling them to discover critical topics and choose the best match for their survey work.
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Yoon ES, Hur S, Curtis LM, Wynia AH, Zheng P, Nair SS, Bailey SC, Serper M, Reese PP, Ladner DP, Wolf MS. A Multifaceted Intervention to Improve Medication Adherence in Kidney Transplant Recipients: An Exploratory Analysis of the Fidelity of the TAKE IT Trial. JMIR Form Res 2022; 6:e27277. [PMID: 35511225 PMCID: PMC9121227 DOI: 10.2196/27277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/23/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inadequate adherence to prescribed immunosuppressive medication regimens among kidney transplant recipients is common, yet interventions are needed to support patients in sustaining adequate adherence to prescribed regimens and achieving optimal transplant outcomes. OBJECTIVE We examined the preliminary fidelity of a transplant center-based, multifaceted adherence monitoring strategy known as TAKE IT. METHODS The TAKE IT strategy includes: (1) routine, online, monthly patient self-report adherence assessments; (2) care alerts directed to nurses; (3) quarterly reports monitoring tacrolimus values and adherence trends; (4) support tools tailored to specific adherence concerns. A 2-arm, patient-randomized trial is underway at two large transplant centers (N=449). To evaluate the initial fidelity of TAKE IT, we investigated patient uptake of monthly adherence assessments during the course of a 3-month period, whether any disparities emerged, and the nature of any reported adherence concerns. RESULTS Among 202 patients randomized and exposed to TAKE IT for 3-months or more, 81% (164/202) completed an adherence assessment, 73% (148/202) completed at least two, and 57% (116/202) completed all monthly assessments. Overall, 50% (82/164) of kidney transplant recipients reported at least one adherence concern over the 3-month assessment period. The most common barriers were classified as regimen-related (eg, regimen complexity), cognitive (eg, forgetfulness), and medical (eg, side effects). Higher-income participants were more likely to complete all surveys compared to lower-income participants (P=.01). CONCLUSIONS TAKE IT demonstrated 81% (164/202) completion of an adherence assessment, 73% (148/202) completion of at least two, and 57% (116/202) completion of all monthly assessments during this brief, initial observation period. Among those that did respond to the online assessments, the majority demonstrated sustained engagement. Additional monitoring modalities could also be offered to meet patient preferences to ensure all patients' medication use can be properly monitored. TRIAL REGISTRATION ClinicalTrials.gov NCT03104868; https://clinicaltrials.gov/ct2/show/NCT03104868.
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Affiliation(s)
- Esther S Yoon
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Scott Hur
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Laura M Curtis
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Aiden H Wynia
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Pauline Zheng
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sumi S Nair
- Mayo Clinic Arizona Transplant Center, Mayo Clinic, Pheonix, AZ, United States
| | - Stacy C Bailey
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.,Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL, United States
| | - Michael S Wolf
- Center for Applied Health Research on Aging, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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10
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Gianaris K, Vargas GB, Johnson M, Yu Y, Wilson E, Perkins JA, Jackson A, Boulware LE, Massie A, Levan ML, Segev DL, Purnell TS. Perceived Susceptibility to Chronic Kidney Disease and Hypertension Self-Management among Black and White Live Kidney Donors. Ethn Dis 2022; 32:101-108. [PMID: 35497403 DOI: 10.18865/ed.32.2.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Despite the societal benefits of live kidney donation, Black donors may be more likely than White donors to develop hypertension (HTN) and chronic kidney disease after donation. Among live kidney donors diagnosed with post-donation HTN, little is known about potential racial/ethnic differences in HTN self-care behaviors and perceived susceptibility to developing kidney disease. Methods We ascertained electronic medical records and phone survey data from live donors enrolled in the multi-center Wellness and Health Outcomes of LivE Donors (WHOLE-Donor) Hypertension Care Study between May 2013 and April 2020. Using multivariable logistic regression models performed January through June 2021, we examined potential associations of donor race/ethnicity with perceived susceptibility to kidney disease and self-care behaviors (ie, Behavioral Risk Factor Surveillance System measure assessing self-reported actions to control high blood pressure). Results The study included 318 US-based live kidney donors who developed post-donation HTN (57.6% female; 78.9% White; 18.6% Black; and mean age 46.7 years at donation). Black donors were equally as likely as White donors to report being moderately or strongly concerned about developing kidney disease (adjusted odds ratio, aOR: 1.27, 95%CI: .66, 2.14, P=.57). Donors with diabetes were more likely than those without diabetes (aOR: 2.43, 95%CI: 1.03, 5.01, P=.04), while donors aged >50 years were less likely than younger donors (aOR: .39, 95%CI: .18, .85, P=.02) to report being moderately or strongly concerned about kidney disease. Overall, 87% of donors reported taking at least one action to help control blood pressure, with no significant differences by sociodemographic factors. Conclusions We found no substantial differences in perceived susceptibility to kidney disease among Black and White donors, despite published evidence that Black donors may experience greater risk of developing kidney disease than White donors. Behavioral interventions to enhance knowledge about future disease risk, attitudes, and self-care strategies among living kidney donors may be beneficial.
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Affiliation(s)
- Kevin Gianaris
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Grecia B Vargas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Morgan Johnson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Yifan Yu
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elena Wilson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jamilah A Perkins
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aswad Jackson
- Diversity Summer Internship Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - L Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Allan Massie
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Macey L Levan
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tanjala S Purnell
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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11
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Song Y, Zhang W, Li Q, Ma W. Medical Data Acquisition and Internet of Things Technology-Based Cerebral Stroke Disease Prevention and Rehabilitation Nursing Mobile Medical Management System. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4646454. [PMID: 35126624 PMCID: PMC8816578 DOI: 10.1155/2022/4646454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/19/2021] [Accepted: 12/31/2021] [Indexed: 11/18/2022]
Abstract
This research was aimed at exploring the application value of a mobile medical management system based on Internet of Things technology and medical data collection in stroke disease prevention and rehabilitation nursing. In this study, on the basis of radio frequency identification (RFID) technology, the signals collected by the sensor were filtered by the optimized median filtering algorithm, and a rehabilitation nursing evaluation model was established based on the backpropagation (BP) neural network. The performance of the medical management system was verified in 32 rehabilitation patients with hemiplegia after stroke and 6 healthy medical staff in the rehabilitation medical center of the hospital. The results showed that the mean square error (MSE) and peak signal-to-noise ratio (PSNR) of the median filtering algorithm after optimization were significantly higher than those before optimization (P < 0.05). When the number of neurons was 23, the prediction accuracy of the test set reached a maximum of 89.83%. Using traingda as the training function, the model had the lowest training time and root mean squared error (RMSE) value of 2.5 s and 0.29, respectively, which were significantly lower than the traingd and traingdm functions (P < 0.01). The error percentage and RMSE of the model reached a minimum of 7.56% and 0.25, respectively, when the transfer functions of both the hidden and input layers were tansig. The prediction accuracy in stages III~VI was 90.63%. It indicated that the mobile medical management system established based on Internet of Things technology and medical data collection has certain application value for the prevention and rehabilitation nursing of stroke patients, which provides a new idea for the diagnosis, treatment, and rehabilitation of stroke patients.
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Affiliation(s)
- Yunna Song
- Mathematics Teaching and Research Section, Qiqihar Medical University, Qiqihar, 161000, China
| | - Wenjing Zhang
- Teaching and Research Section of Computer Science, Qiqihar Medical University, Qiqihar 161000, China
| | - Qingjiang Li
- Teaching and Research Section of Computer Science, Qiqihar Medical University, Qiqihar 161000, China
| | - Wenhui Ma
- Computer Experimental Teaching Center, Qiqihar Medical University, Qiqihar 161000, China
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12
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Abasi S, Yazdani A, Kiani S, Mahmoudzadeh‐Sagheb Z. Effectiveness of mobile health-based self-management application for posttransplant cares: A systematic review. Health Sci Rep 2021; 4:e434. [PMID: 34869915 PMCID: PMC8596943 DOI: 10.1002/hsr2.434] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIMS Patients after transplantation need medical management for the rest of their lives, and self-management seems to lead to greater adherence to medical standards, improve early physical changes, and increase patient empowerment. The main objective of this article is to systematic review of the consideration to mobile health applications (m-Health apps) used in transplantation. METHODS A systematic search was conducted MEDLINE (through PubMed), Web of Science, Scopus, and Science Direct from inception to November 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was used in this study. Comprehensive research was carried out using a combination of keywords and MeSH terms associated with m-Health, empowerment, self-management, and transplantation. Two independent reviewers screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Eligible studies were original research articles that included posttransplant care and mobile phone-based applications to support self-management and self-care. Also, thesis, book chapters, letters to editors, short briefs, reports, technical reports, book reviews, systematic reviews, or meta-analysis were excluded. RESULTS We divided all the reviewed articles into four categories, self-management (medication adherence, adherence to medical regimen, and remote monitoring), evaluation, interaction, and interface; 37.5% of the studies were focused on lung transplantation. In 56.25% of the studies, medication adherence was considered because one of the main reasons for the rejection and graft loss is stated medication nonadherence. Also, 62.5% of the studies demonstrated that the use of m-health improved medication adherence and self-management in transplantation. CONCLUSIONS The use of m-Health apps interventions to self-management after transplantation has shown promising feasibility and acceptability, and there is modest evidence to support the efficacy of these interventions. We found that m-Health solutions can help the patient in self-management in many ways after transplantation.
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Affiliation(s)
- Sanaz Abasi
- Department of Health Information ManagementSchool of Health Management and Information Sciences, Shiraz University of Medical SciencesShirazIran
| | - Azita Yazdani
- Clinical Education Research Center, Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical SciencesShirazIran
| | - Shamim Kiani
- Department of Health Information ManagementSchool of Health Management and Information Sciences, Shiraz University of Medical SciencesShirazIran
| | - Zahra Mahmoudzadeh‐Sagheb
- Department of Health Information ManagementHealth Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical SciencesShirazIran
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13
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Yadav A, Singh P. Telehealth Use by Living Kidney Donor Transplant Programs During the COVID-19 Pandemic and Beyond: a Practical Approach. CURRENT TRANSPLANTATION REPORTS 2021; 8:257-262. [PMID: 34812402 PMCID: PMC8597544 DOI: 10.1007/s40472-021-00339-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/20/2022]
Abstract
Purpose of Review COVID-19 pandemic led to a decline in living kidney donor evaluations and transplants. This was due to concerns for donor and recipient safety, restrictions on elective cases, and diversion of staff and resources in centers with a higher incidence of COVID-19 infections. Telehealth was explored as a strategy to continue living donor evaluations during the pandemic, but faced barriers including restrictive physician licensing, reduced reimbursement, lack of infrastructure, prohibitive local policies, limited exam, and personal biases. This review highlights these barriers and potential solutions. Recent Findings Telehealth usage in the transplant population improves medication adherence, reduces hospitalization rates for recipients, and makes living donor evaluation convenient. Transplant centers have implemented telehealth successfully for living kidney donor evaluations. Broad use of telemedicine will be possible only if policies support the changing landscape of healthcare delivery. Summary Telehealth may increase access to timely kidney transplants by expediting living kidney donor evaluations. However, supportive infrastructure, regulatory policies, and reimbursement are needed to sustain access to telehealth for living kidney donor evaluation and care.
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Affiliation(s)
- Anju Yadav
- Division of Nephrology, Thomas Jefferson University Hospital, 833 Chestnut St, Suite 700, Philadelphia, PA USA
| | - Pooja Singh
- Division of Nephrology, Thomas Jefferson University Hospital, 833 Chestnut St, Suite 700, Philadelphia, PA USA
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14
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Taber DJ, Fleming JN, Su Z, Mauldin P, McGillicuddy JW, Posadas A, Gebregziabher M. Significant hospitalization cost savings to the payer with a pharmacist-led mobile health intervention to improve medication safety in kidney transplant recipients. Am J Transplant 2021; 21:3428-3435. [PMID: 34197699 DOI: 10.1111/ajt.16737] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
This was an economic analysis of a 12-month, parallel arm, randomized controlled trial in adult kidney recipients 6 to 36 months posttransplant (NCT03247322). All participants received usual posttransplant care, while the intervention arm received supplemental clinical pharmacist-led medication therapy monitoring and management, via a smartphone-enabled mHealth app, integrated with risk-based televisits. Hospitalization charges were captured from the study institution accounts payable and non-study institution hospitalization charges were estimated using multiple imputation. Multivariable modeling was used to assess the impact of the intervention on charges. The intervention significantly reduced rates of hospitalization (1.08 per patient-year in the control arm vs 0.65 per patient-year in the intervention arm, p = .007). The control arm had estimated hospitalization costs of $870,468 vs $390,489 in the intervention arm. Modeling demonstrated a 49% lower hospitalization charge risk in the intervention arm (RR 0.51, 95% CI 0.28-0.91; p = .022). From a payer or societal perspective, the net estimated cost savings, after accounting for intervention delivery costs, was $368,839, with a return on investment (ROI) of $4.30 for every $1 spent. These results demonstrate that a mHealth-enabled, pharmacist-led intervention significantly reduced hospitalization costs for payers over a 12-month period and has a positive ROI.
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Affiliation(s)
- David J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James N Fleming
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John W McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aurora Posadas
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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15
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Schwantes IR, Axelrod DA. Technology-Enabled Care and Artificial Intelligence in Kidney Transplantation. CURRENT TRANSPLANTATION REPORTS 2021; 8:235-240. [PMID: 34341714 PMCID: PMC8317681 DOI: 10.1007/s40472-021-00336-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 01/24/2023]
Abstract
Purpose of Review Artificial intelligence (AI), machine learning, and technology-enabled remote patient care have evolved rapidly and have now been incorporated into many aspects of medical care. Transplantation is fortunate to have large data sets upon which machine learning algorithms can be constructed. AI are now available to improve pretransplant management, donor selection, and post-operative management of transplant patients. Recent Findings Changes in patient and donor characteristics warrant new approaches to listing and organ acceptance practices. Machine learning has been employed to optimize donor selection to identify patients likely to benefit from transplantation of higher risk organs, increasing organ discard and reducing waitlist mortality. These models have greater precisions and predictive ability than currently employed metrics including the Kidney Donor Profile Index and the expected posttransplant survival models. After transplant, AI tools have been developed to optimize immunosuppression management, track patients adherence, and assess graft survival. Summary AI and technology-enabled management tools are now available throughout the transplant journey. Unfortunately, those are frequently not available at the point of decision (patient listing, organ acceptance, posttransplant clinic), limiting utilization. Incorporation of these tools into the EMR, the Donor Net® organ offer system, and mobile devices is vital to ensure widespread adoption.
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Affiliation(s)
- Issac R Schwantes
- Department of Surgery, Oregon Health & Science University, Portland, OR USA
| | - David A Axelrod
- Organ Transplant Center, University of Iowa, 200 Hawkins Dr, Iowa City, LA 52240 USA
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16
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Taber DJ, Hirsch J, Keys A, Su Z, McGillicuddy JW. Etiologies and Outcomes Associated With Tacrolimus Levels Out of a Typical Range That Lead to High Variability in Kidney Transplant Recipients. Ther Drug Monit 2021; 43:401-407. [PMID: 33560095 PMCID: PMC8119313 DOI: 10.1097/ftd.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/27/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND High tacrolimus intrapatient variability (tac IPV) is associated with poor outcomes in kidney transplantation, including rejection, donor-specific antibodies, and graft loss. A common cause of high tac IPV is related to patient nonadherence, but this is yet to be conclusively demonstrated. METHODS This was a longitudinal cohort study comprising adult kidney recipients, who received transplants between 2015 and 2017, with follow-ups through February 2020. The goal of this study was to identify the most common etiologies of tac levels outside the typical range, which lead to high tac IPV, and assess the etiology-specific associations between high tac IPV and graft outcomes. Multivariate Cox regression was used to assess time-to-event analyses. RESULTS In total, 537 adult kidney recipients were included; 145 (27%) were identified as having a high tac IPV (>40%) 3-102 months post-transplant. Common etiologies of tac levels significantly outside the standard goal range (6-12 ng/mL) leading to high tac IPV included patient nonadherence (20%), infections (19%), tac-related toxicities (17%), and undocumented issues (27%). In multivariable Cox modeling, those with high tac IPV because of nonadherence had a 3.5 times higher risk of late acute rejection (P = 0.019) and 2.2 times higher risk of late graft loss (P = 0.044). No other etiologies in the typical tac level range were significantly associated with either acute rejection or graft loss. CONCLUSIONS Although high tac IPV has many causes, only high tac IPV caused by nonadherence is consistently associated with poor allograft outcomes.
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Affiliation(s)
- David J Taber
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston SC
| | - Jason Hirsch
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston SC
| | - Alison Keys
- College of Pharmacy, Medical University of South Carolina, Charleston SC
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston SC
| | - John W McGillicuddy
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston SC
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17
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St. Peter WL, Aungst TD. Twenty-First Century Solutions to Increase Medication Optimization and Safety in Kidney Transplant Patients. Clin J Am Soc Nephrol 2021; 16:679-681. [PMID: 33931416 PMCID: PMC8259472 DOI: 10.2215/cjn.04160321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Wendy L. St. Peter
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Timothy D. Aungst
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
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18
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Gonzales HM, Fleming JN, Gebregziabher M, Posadas-Salas MA, Su Z, McGillicuddy JW, Taber DJ. Pharmacist-Led Mobile Health Intervention and Transplant Medication Safety: A Randomized Controlled Clinical Trial. Clin J Am Soc Nephrol 2021; 16:776-784. [PMID: 33931415 PMCID: PMC8259471 DOI: 10.2215/cjn.15911020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/24/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Medication safety events are predominant contributors to suboptimal graft outcomes in kidney transplant recipients. The goal of this study was to examine the efficacy of improving medication safety through a pharmacist-led, mobile health-based intervention. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a 12-month, single-center, prospective, parallel, two-arm, single-blind, randomized controlled trial. Adult kidney recipients 6-36 months post-transplant were eligible. Participants randomized to intervention received supplemental clinical pharmacist-led medication therapy monitoring and management via a mobile health-based application, integrated with risk-guided televisits and home-based BP and glucose monitoring. The application provided an accurate medication regimen, timely reminders, and side effect surveys. Both the control and intervention arms received usual care, including serial laboratory monitoring and regular clinic visits. The coprimary outcomes were to assess the incidence and severity of medication errors and adverse events. RESULTS In total, 136 kidney transplant recipients were included, 68 in each arm. The mean age was 51 years, 57% were male, and 64% were Black individuals. Participants receiving the intervention experienced a significant reduction in medication errors (61% reduction in the risk rate; incident risk ratio, 0.39; 95% confidence interval, 0.28 to 0.55; P<0.001) and a significantly lower incidence risk of Grade 3 or higher adverse events (incident risk ratio, 0.55, 95% confidence interval, 0.30 to 0.99; P=0.05). For the secondary outcome of hospitalizations, the intervention arm demonstrated significantly lower rates of hospitalizations (incident risk ratio, 0.46; 95% confidence interval, 0.27 to 0.77; P=0.005). CONCLUSIONS We demonstrated a significant reduction in medication errors, adverse events, and hospitalizations using a pharmacist-led, mobile health-based intervention.
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Affiliation(s)
- Haley M. Gonzales
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - James N. Fleming
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | | | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - John W. McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - David J. Taber
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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19
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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20
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Fleming JN, Gebregziabher M, Posadas A, Su Z, McGillicuddy JW, Taber DJ. Impact of a pharmacist-led, mHealth-based intervention on tacrolimus trough variability in kidney transplant recipients: A report from the TRANSAFE Rx randomized controlled trial. Am J Health Syst Pharm 2021; 78:1287-1293. [PMID: 33821958 DOI: 10.1093/ajhp/zxab157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Nonadherence is a leading cause of death-censored allograft loss in kidney transplant recipients. Strong associations have tied tacrolimus intrapatient variability (IPV) to degree of nonadherence and high tacrolimus IPV to clinical endpoints such as rejection and allograft loss. Nonadherence is a dynamic, complex problem best targeted by multidimensional interventions, including mobile health (mHealth) technologies. METHODS This was a secondary planned analysis of a 12-month, parallel, 2-arm, semiblind, 1:1 randomized controlled trial involving 136 adult kidney transplant recipients. The primary aims of the TRANSAFE Rx study were to assess the efficacy of a pharmacist-led, mHealth-based intervention in improving medication safety and health outcomes for kidney transplant recipients as compared to usual care. RESULTS Patients were randomized equally to 68 patients per arm. The intervention arm demonstrated a statistically significant decrease in tacrolimus IPV over time as compared to the control arm (P = 0.0133). When analyzing a clinical goal of tacrolimus IPV of less than 30%, the 2 groups were comparable at baseline (P = 0.765), but significantly more patients in the intervention group met this criterion at month 12 (P = 0.033). In multivariable modeling, variables that independently impacted tacrolimus IPV included time, treatment effect, age, and warm ischemic time. CONCLUSION This secondary planned analysis of an mHealth-based, pharmacist-led intervention demonstrated an association between the active intervention in the trial and improved tacrolimus IPV. Further prospective studies are required to confirm the mutability of tacrolimus IPV and impact of reducing tacrolimus IPV on long-term clinical outcomes.
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Affiliation(s)
- James N Fleming
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Aurora Posadas
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - John W McGillicuddy
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - David J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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21
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Rohan VS, Pilch N, Cassidy D, McGillicuddy J, White J, Lin A, Nadig SN, Taber DJ, Dubay D, Baliga PK. Maintaining Equity and Access: Successful Implementation of a Virtual Kidney Transplantation Evaluation. J Am Coll Surg 2020; 232:444-449. [PMID: 33359232 DOI: 10.1016/j.jamcollsurg.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Maintaining access to kidney transplantation during a pandemic is a challenge, particularly for centers that serve a large rural and minority patient population with an additional burden of travel. The aim of this article was to describe our experience with the rollout and use of a virtual pretransplantation evaluation platform to facilitate ongoing transplant waitlisting during the early peak of the COVID-19 pandemic. STUDY DESIGN This is a retrospective analysis of the process improvement project implemented to continue the evaluation of potential kidney transplantation candidates and ensure waitlist placement during the COVID-19 pandemic. Operational metrics include transplantation volume per month, referral volume per month, pretransplantation patients halted before completing an evaluation per month, evaluations completed per month, and patients waitlisted per month. RESULTS Between April and September 2020, a total of 1,258 patients completed an evaluation. Two hundred and forty-seven patients were halted during this time period before completing a full evaluation. One hundred and fifty-two patients were presented at selection and 113 were placed on the waitlist. In addition, the number of patients in the active referral phase was able to be reduced by 46%. More evaluations were completed within the virtual platform (n = 930 vs n = 880), yielding similar additions to the waitlist in 2020 (n = 282) vs 2019 (n = 308) despite the COVID-19 pandemic. CONCLUSIONS The virtual platform allowed continued maintenance of a large kidney transplantation program despite the inability to have in-person visits. The value of this platform will likely transform our approach to the pretransplantation process and provides an additional valuable method to improve patient equity and access to transplantation.
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Affiliation(s)
- Vinayak S Rohan
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina.
| | - Nicole Pilch
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Deborah Cassidy
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - John McGillicuddy
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Jared White
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Angello Lin
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Satish N Nadig
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - David J Taber
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Derek Dubay
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
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22
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Duettmann W, Naik MG, Zukunft B, Osmonodja B, Bachmann F, Choi M, Roller R, Mayrdorfer M, Halleck F, Schmidt D, Budde K. eHealth in transplantation. Transpl Int 2020; 34:16-26. [DOI: 10.1111/tri.13778] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/17/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Wiebke Duettmann
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Bilgin Osmonodja
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Roland Roller
- German Research Center for Artificial Intelligence Berlin Germany
| | - Manuel Mayrdorfer
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
| | - Danilo Schmidt
- Business Division IT Department of Research and Teaching Charité—Universitätsmedizin Berlin Berlin Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care Charité – Universitätsmedizin Berlin Berlin Germany
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23
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Flynn A. Informatics and technology enable us to learn from every patient: Pharmacists' many roles in learning health systems. Am J Health Syst Pharm 2019; 76:1095-1096. [PMID: 31361872 DOI: 10.1093/ajhp/zxz118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Allen Flynn
- Department of Learning Health Sciences, Medical School, University of Michigan, Ann Arbor, MI
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