Use of an automated clinical management system improves outpatient immunosuppressive care following liver transplantation

Telemedicine based remote monitoring after liver transplantation: Feasible in a select group and a more stringent control of immunosuppression

Telemedicine gained interest in liver transplant patients but focused until now on the early post‐operative period. This prospective cohort study assessed feasibility, safety, and clinical beneficial effects of a telemedicine based remote monitoring program (TRMP) for the chronic follow‐up of adult liver transplant recipients. Between November 2017 and August 2019, a total of 87 of the 115 selected patients (76%) started the TRMP. Over the 2 years study period, none of the patients switched to standard follow‐up: 39/87 (45%) continued to do this autonomously and 48/87 (55%) stopped to report their data personally but communicated their lab values to the nurse. The other 28/115 (11%) patients who did not accept the TRMP continued the standard follow‐up. There was no difference in educational level between the three groups. Remote monitoring did not result in an increase in liver graft rejection and need of hospitalization. TRMP was associated with a higher number of tacrolimus level determinations and tacrolimus blood level concentrations could be kept lower. In conclusion, our results show that in patients with a stable clinical condition there is a high willingness to participate in TRMP and that this approach is safe. Remote monitoring allowed a stringent follow‐up of tacrolimus levels.

Translation of evidence into kidney transplant clinical practice: managing drug-lab interactions by a context-aware clinical decision support system

BACKGROUND

Drug-laboratory (lab) interactions (DLIs) are a common source of preventable medication errors. Clinical decision support systems (CDSSs) are promising tools to decrease such errors by improving prescription quality in terms of lab values. However, alert fatigue counteracts their impact. We aimed to develop a novel user-friendly, evidence-based, clinical context-aware CDSS to alert nephrologists about DLIs clinically important lab values in prescriptions of kidney recipients.

METHODS

For the most frequently prescribed medications identified by a prospective cross-sectional study in a kidney transplant clinic, DLI-rules were extracted using main pharmacology references and clinical inputs from clinicians. A CDSS was then developed linking a computerized prescription system and lab records. The system performance was tested using data of both fictitious and real patients. The "Questionnaire for User Interface Satisfaction" was used to measure user satisfaction of the human-computer interface.

RESULTS

Among 27 study medications, 17 needed adjustments regarding renal function, 15 required considerations based on hepatic function, 8 had drug-pregnancy interactions, and 13 required baselines or follow-up lab monitoring. Using IF & THEN rules and the contents of associated alert, a DLI-alerting CDSS was designed. To avoid alert fatigue, the alert appearance was considered as interruptive only when medications with serious risks were contraindicated or needed to be discontinued or adjusted. Other alerts appeared in a non-interruptive mode with visual clues on the prescription window for easy, intuitive notice. When the system was used for real 100 patients, it correctly detected 260 DLIs and displayed 249 monitoring, seven hepatic, four pregnancy, and none renal alerts. The system delivered patient-specific recommendations based on individual lab values in real-time. Clinicians were highly satisfied with the usability of the system.

CONCLUSIONS

To our knowledge, this is the first study of a comprehensive DLI-CDSS for kidney transplant care. By alerting on considerations in renal and hepatic dysfunctions, maternal and fetal toxicity, or required lab monitoring, this system can potentially improve medication safety in kidney recipients. Our experience provides a strong foundation for designing specialized systems to promote individualized transplant follow-up care.

Feasibility of Using High-Contrast Grating as a Point-of-Care Sensor for Therapeutic Drug Monitoring of Immunosuppressants

Point-of-care (POC) testing has demonstrated great transformative potential in personalized medicine. In particular, patients undergoing transplantation require POC testing to ensure appropriate serum immunosuppressant levels so as to maintain adequate graft function and survival. However, no suitable POC device for monitoring immunosuppressant levels is currently available. Exploiting the latest advances in metamaterials can lead to a breakthrough in POC testing. A high-contrast grating (HCG) biosensor is a low-cost, compact, simple-to-fabricate, and easy-to-operate structure. It is highly sensitive and robust in surface-based biomarker detection, which is favorable for the efficiency of a POC device. In this study, the feasibility of using an HCG as a POC sensor for therapeutic drug monitoring of immunosuppressants was evaluated. The detection efficiency of the most commonly prescribed immunosuppressive medication cyclosporine A by using this sensor was demonstrated to be comparable to those of conventional commercial kits, suggesting that the sensor has the potential to be used as a rapid detection and feedback platform for increasing drug compliance and improving new organ transplant survival.

Development and Psychometric Testing of Liver Transplant Therapeutic Adherence Questionnaire in a Triphasic Mixed-Method Study

INTRODUCTION

Due to the high nonadherence rate to posttransplant regimen and medical indications among liver transplant recipients, systematic patient-centered interventions are needed to improve the medium- and long-term graft and patient survival outcomes.

OBJECTIVE

The aim of this study was to develop and test the psychometric properties of Liver Transplant Therapeutic Adherence Questionnaire.

DESIGN

A mixed-method instrument design was conducted in 3 phases: (1) initial item collection was generated by inductive content analysis on internationally available resources, (2) item screening was carried out by a 3-member committee and 25 domain experts including nurses and physicians aiming to establish content validity, and (3) data were collected from 247 liver transplant recipients in May 2016 for psychometric testing.

RESULTS

A total of 221 knowledge statements were extracted as potential adherence assessment items. The qualitative screening phase resulted in top 35 important items. The second screening phase was performed quantitatively by 25 experts (n = 14 nurses, n = 7 gastroenterologists and hepatologists, and n = 4 transplant surgeons). A total of 16 items were associated with statistically significant content validity ratio values (≥0.37) to be included in the final questionnaire. Exploratory factor analysis revealed a distinct 4-factor structure that was labeled as: daily activities (α = .93), immunization (α = .93), nutrition (α = .92), and major complications (α = .79).

DISCUSSION

Our results reveal evidence of acceptable reliability and validity for Liver Transplant Therapeutic Adherence Questionnaire. This instrument makes it possible to measure recipients' therapeutic adherence in both domains of research and practice.

Adherence to immunosuppressive therapy following liver transplantation: an integrative review

OBJECTIVE

to investigate the evidence available in the literature on non-adherence to immunosuppressive therapy among patients undergoing liver transplantation.

METHOD

integrative literature review, including research whose sample consisted of patients aged over 18 years undergoing liver transplantation. It excluded those containing patients undergoing multiple organ transplants. For the selection of articles, Medline / Pubmed, CINAHL, LILACS, Scopus and Embase were searched. The search period corresponded to the initial date of indexation of different bases, up to the deadline of February 10, 2015, using controlled and uncontrolled descriptors: liver transplantation, hepatic transplantation, liver orthotopic transplantation, medication adherence, medication non-adherence, medication compliance and patient compliance.

RESULTS

were located 191 investigations, 10 of which met the objectives of the study and were grouped into four categories, namely: educational process and non-adherence; non-adherence related to the number of daily doses of immunosuppressive medications; detection methods for non-adherence and side effects of therapy.

CONCLUSION

there were risk factors related to the health service, such as control and reduction of the number of doses; related to the individual, such as being male, divorced, alcohol or other substances user, exposed to low social support and being mentally ill.

Longitudinal Analysis of Computerized Alerts for Laboratory Monitoring of Post-liver Transplant Immunosuppressive Care

Post-liver transplant patients require lifelong immunosuppressive care and monitoring. Computerized alerts can aid laboratory monitoring, but it is unknown how the distribution of alerts changes over time. We describe the changes over time of the distribution of computerized alerts for laboratory monitoring of post-liver transplant immunosuppressive care. Data were collected for post-liver transplant patients transplanted and managed at Intermountain Healthcare between 2005 and 2012. Alerts were analyzed based on year triggered, time since transplantation, hospitalization status, alert type, action taken (accepted or rejected), reason given for the action taken, and narrative comments. Alerts for overdue laboratory testing became more prevalent as time since transplantation increased. There is an increased need to support monitoring for overdue laboratory testing as the time since transplantation increases. Alerts should support providers as they monitor the evolving needs of post-transplant patients over time. We identify opportunities for improving laboratory monitoring of post-liver transplant patients.

Assessment of readiness for clinical decision support to aid laboratory monitoring of immunosuppressive care at U.S. liver transplant centers

BACKGROUND

Following liver transplantation, patients require lifelong immunosuppressive care and monitoring. Computerized clinical decision support (CDS) has been shown to improve post-transplant immunosuppressive care processes and outcomes. The readiness of transplant information systems to implement computerized CDS to support post-transplant care is unknown.

OBJECTIVES

a) Describe the current clinical information system functionality and manual and automated processes for laboratory monitoring of immunosuppressive care, b) describe the use of guidelines that may be used to produce computable logic and the use of computerized alerts to support guideline adherence, and c) explore barriers to implementation of CDS in U.S. liver transplant centers.

METHODS

We developed a web-based survey using cognitive interviewing techniques. We surveyed 119 U.S. transplant programs that performed at least five liver transplantations per year during 2010-2012. Responses were summarized using descriptive analyses; barriers were identified using qualitative methods.

RESULTS

Respondents from 80 programs (67% response rate) completed the survey. While 98% of programs reported having an electronic health record (EHR), all programs used paper-based manual processes to receive or track immunosuppressive laboratory results. Most programs (85%) reported that 30% or more of their patients used external laboratories for routine testing. Few programs (19%) received most external laboratory results as discrete data via electronic interfaces while most (80%) manually entered laboratory results into the EHR; less than half (42%) could integrate internal and external laboratory results. Nearly all programs had guidelines regarding pre-specified target ranges (92%) or testing schedules (97%) for managing immunosuppressive care. Few programs used computerized alerting to notify transplant coordinators of out-of-range (27%) or overdue laboratory results (20%).

CONCLUSIONS

Use of EHRs is common, yet all liver transplant programs were largely dependent on manual paper-based processes to monitor immunosuppression for post-liver transplant patients. Similar immunosuppression guidelines provide opportunities for sharing CDS once integrated laboratory data are available.