Nonadherence with Immunosuppressive Drugs: Us Compared with European Kidney Transplant Recipients

Non-adherence assessment to immunosuppressant therapy with a self-report questionnaire and intra-patient variability in renal transplantation: risk factors and clinical correlations

BACKGROUND

Non-adherence (NA) to immunosuppressive drugs is to date considered a crucial issue in kidney transplanted patients (KTRs), leading to de-novo donor-specific anti-HLA antibodies (dnDSA) development, acute and chronic rejection, and at least graft loss. However, NA assessment is challenging, often leading to underestimation in real-life settings.

METHODS

NA evaluation in all KTRs referred to our post-transplantation clinic in the period between 01/01-15/07/2018 with self-report questionnaire combined to intra-patient variability (IPV) of the pivotal immunosuppressive drug (based on trough levels of tacrolimus/mTOR inhibitor).

RESULTS

Based on both questionnaire and IPV, 86 out of the 504 tested KTRs (17%) were classified as NA. Male gender (OR, 2.0; 95% confidence interval [CI], 1.2 to 3.4), high educational level (OR for KTRs with a degree, 1.8 [95% CI, 1.0 to 3.1]), employment (OR, 2.0 [95% CI, 1.2 to 3.3]), young age at transplantation (P=0.017), longer time on the waiting list and after transplantation (P=0.027 and 0.049 respectively) were all associated with NA. High IPV was mostly documented in KTRs treated with the twice-daily formulation of the immunosuppressive drug (OR, 1.5 [95% CI, 1.0 to 2.1]) and better associated with dnDSA appearance (OR, 2.1 [95% CI, 1.1 to 3.9]).

CONCLUSIONS

NA is a significant problem, difficult to assess, and can lead to dnDSA development also in our population. Identifying risk factors for NA might be an underestimated tool to improve graft and patient outcome in KTRs.

Graft Failure Due to Nonadherence among 150 Prospectively-Followed Kidney Transplant Recipients at 18 Years Post-transplant: Our Results and Review of the Literature

Background: We previously reported that graft failure due to nonadherence (GFNA) was a major cause of graft loss in kidney transplantation. Here, among 150 prospectively-followed kidney transplant recipients at 18 years post-transplant, we provide: updated (longer-term) estimates of cause-specific graft loss probabilities, risk factors for developing GFNA, and detailed characterizations of patients’ overt nonadherent (NA) behavior, including timing, extent, and clinical consequences. Methods: Determination of the patient becoming NA in taking his/her immunosuppressive medications, and the underlying cause of graft loss, were determined prospectively by the attending physicians. For never-functioning-graft, GFNA, GF due to causes other than NA (Other GF), and death with a functioning graft (DWFG), cumulative incidence functions were used to estimate the cumulative probabilities of cause-specific graft loss. Cox stepwise regression was used to determine significant multivariable predictors for the hazard rate of developing GFNA. Results: GFNA was a major cause of graft loss (22/150 patients), particularly among African-American and Hispanic recipients <50 years of age-at-transplant (20/56 experienced GFNA), with estimated percentages of such patients ever developing GFNA ranging between 36.9 and 41.5%. These patients were also at a higher risk of developing Other GF. For the remaining patients (2/94 experienced GFNA), estimated percentages of ever-developing GFNA were much lower (range: 0.0−6.7%). The major cause of graft loss among recipients ≥50 years of age was DWFG; GFNA rarely occurred among older recipients. In 21/22 GFNA patients, NA behavior lasted continuously from the time of developing NA until GFNA. In total, 28/150 patients became NA, and 67.9% (19/28) occurred beyond 36 months post-transplant. A total of 25 of 28 NA patients (89.3%) developed biopsy-proven acute rejection and/or chronic rejection that was directly attributed to the NA behavior. Lastly, 25/28 admitted to NA behavior, with financial and psychological components documented in 71.4% (20/28) and 96.4% (27/28) of NA cases, respectively. Conclusions: These results highlight the importance of performing serial monitoring of patients for overt NA behavior throughout their post-transplant follow-up. Financial and psychological components to NA behavior need to be simultaneously addressed with the goal of achieving complete avoidance/elimination of NA behavior among higher risk patients.

Benefit of a pharmacist-led intervention for medication management of renal transplant patients: a controlled before-and-after study

Aims

To assess the effect of a pharmacist-led intervention, using Barrows cards method, during the first year after renal transplantation, on patient knowledge about their treatment, medication adherence and exposure to treatment in a French cohort.

Methods

We conducted a before-and-after comparative study between two groups of patients: those who benefited from a complementary pharmacist-led intervention [intervention group (IG), n = 44] versus those who did not [control group (CG), n = 48]. The pharmacist-led intervention consisted of a behavioral and educational interview at the first visit (visit 1). The intervention was assessed 4 months later at the second visit (visit 2), using the following endpoints: treatment knowledge, medication adherence [proportion of days covered (PDC) by immunosuppressive therapy] and tacrolimus exposure.

Results

At visit 2, IG patients achieved a significantly higher knowledge score than CG patients (83.3% versus 72.2%, p = 0.001). We did not find any differences in treatment exposure or medication adherence; however, the intervention tended to reduce the proportion of non-adherent patients with low knowledge scores. Using the PDC by immunosuppressive therapy, we identified 10 non-adherent patients (10.9%) at visit 1 and six at visit 2.

Conclusions

Our intervention showed a positive effect on patient knowledge about their treatment. However, our results did not show any improvement in overall medication adherence, which was likely to be because of the initially high level of adherence in our study population. Nevertheless, the intervention appears to have improved adherence in non-adherent patients with low knowledge scores.

Medication non-adherence after kidney transplantation: A critical appraisal and systematic review

Medication non-adherence is one of the most important causes for shortened graft survival subsequently leading to a reduction in kidney graft survival results. Our aim was to provide an overview of its prevalence, risk factors, diagnostic methods and interventions to improve adherence in kidney transplant recipients. Therefore, we systematically searched the databases PubMed, COCHRANE Library, Web of Science and EMBASE for studies addressing "medication adherence", "compliance", "adherence", "kidney transplantation" and "life style factors". We identified 96 studies that satisfied our inclusion criteria. A problematic lack of a uniformly accepted definition for non-adherence was found, consequently leading to a wide range in non-adherence prevalence (36-55%). Using one uniformly accepted non-adherence definition should therefore be encouraged. A wide range in diagnostic methods makes it difficult to accurately detect non-adherence. Heterogeneous results of intervention studies make it difficult to select the best adherence enhancing method, challenging the battle against medication non-adherence. Literature suggests a combination of personalized interventions, based on patient-specific non-adherent behavior, to be most successful in improvement of adherence. High quality diagnostic methods and multidisciplinary, personalized interventions with focus on relevant clinical outcome are essential in overcoming medication non-adherence in kidney transplant recipients.

Multilevel factors are associated with immunosuppressant nonadherence in heart transplant recipients: The international BRIGHT study

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4-continent, 11-country cross-sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants-defined as any deviation in taking or timing adherence and/or dose reduction-was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale^© (BAASIS^© ) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health-related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out-of-pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels.

Refill-Based Medication Use Quality Measures in Kidney Transplant Recipients: Examination of Proportion of Days Covered and Medication Possession Ratio

BACKGROUND

The Pharmacy Quality Alliance's definition of proportion of days covered (PDC) and medication possession ratio (MPR) have not been examined as potential quality measures in the kidney transplant recipient population.

OBJECTIVES

To (a) describe the frequency distribution of MPR and PDC using mycophenolic acid products in a real-world kidney transplant recipient population and (b) evaluate associations between MPR and PDC with late (> 90 days after transplantation) biopsy-proven acute rejection (BPAR).

METHODS

This was a retrospective cohort study combining data from the Wisconsin Allograft Recipient Database with University of Wisconsin (UW) Health Specialty Pharmacy prescription claims and dispensing data from March 10, 2006, to June 30, 2012. Patients who met criteria for persistence filling mycophenolic acid prescriptions at UW Health Specialty Pharmacy in the first year following discharge from kidney transplantation surgery hospitalization were included. Patients were excluded if they were enrolled in a clinical trial, if they had BPAR within 90 days of transplantation, or if they did not have panel reactive antibody data available. PDC and MPR were calculated over 360 days after discharge, and multivariable analyses were performed to determine if there were associations between PDC or MPR with late BPAR within 3 years.

RESULTS

This study included 388 patients. The incidence of 3-year late BPAR was 5.1% (n = 20). Characteristics of patients who experienced late BPAR were largely consistent with those who did not experience late BPAR, with the exception of number of hospital readmissions, which was higher among patients who experienced late BPAR. The frequency distribution of PDC and MPR exhibited a skewed left distribution, with a median PDC of 0.972 and a median MPR of 1.000. Higher PDC was associated with lower odds of late BPAR (OR = 0.041, 95% CI = 0.004-0.417) in multivariable analysis, as was a higher MPR (OR = 0.041, 95% CI = 0.004-0.419).

CONCLUSIONS

MPR and PDC may be calculated from data available to pharmacies and health plans, and each was associated with 3-year late BPAR among patients who did not experience early BPAR. However, the construct validity of these medication adherence measures requires further study.

DISCLOSURES

This study was not funded. The authors report no conflicts of interest and no relevant financial interests related to the products or services discussed in this article. Study concept and design were contributed by Hofmeyer, along with Look and Hager. Hager took the lead in data collection, along with the other authors. Data interpretation was performed by Look, along with the other authors. The manuscript was primarily written by Hofmeyer, assisted by Look and Hager, and revised by all of the authors.

Adherence in pediatric kidney transplant recipients: solutions for the system

Non-adherence remains a significant problem among pediatric (and adult) renal transplant recipients. Non-adherence among solid organ transplant recipients results in US$15-100 million annual costs. Estimates of non-adherence range from 30 to 70% among pediatric patients. Research demonstrates that a 10% decrement in adherence is associated with 8% higher hazard of graft failure and mortality. Focus has begun to shift from patient factors that impact adherence to the contributing healthcare and systems factors. The purpose of this review is to describe problems within the systems implicated in non-adherence and potential solutions that may be related to positive adherence outcomes. Systems issues include insurance and legal regulations, provider and care team barriers to optimal care, and difficulties with transitioning to adult care. Potential solutions include recognition of how systems can work together to improve patient outcomes through improvements in insurance programs, a multi-disciplinary care team approach, evidence-based medical management, pharmacy-based applications and interventions to simplify medication regimens, improved transition protocols, and telehealth/technology-based multi-component interventions. However, there remains a significant lack of reliability in the application of these potential solutions to systems issues that impact patient adherence. Future efforts should accordingly focus on these efforts, likely by leveraging quality improvement and related principles, and on the investigation of the efficacy of these interventions to improve adherence and graft outcomes.

Adherence in Adolescent and Young Adult Kidney Transplant Recipients

Poor adherence to immunosuppressive medications may be the most important barrier to long term graft survival. An understanding of medication adherence and its determinants is critical to addressing this important problem. In this paper, we will review the different ways in which adherence may be compromised, summarize the evidence that young people constitute a particularly high risk group, and consider the consequences and impact of poor adherence. We will also review the determinants of adherence, including characteristics of the patient and family, the treatment regimen, the healthcare team and its organization, and the healthcare system. We will highlight the most common barriers to adherence identified by young people, and consider different methods of measuring adherence, along with the advantages and limitations of each. Finally, we will consider possible intervention strategies to improve adherence in young people.

An Ecological Perspective on Medication Adherence

Adherence to a prescribed medication regimen is influenced not only by characteristics of the individual patient, but also by factors within the patient’s environment, or so-called system level factors. Until now, however, health care system factors have received relatively little attention in explaining medication nonadherence. Ecological models might serve as a framework to help explain the influence of health care system factors on patient behavior (e.g., adherence). In an ecological model, different levels of factors influence patients’ behavior, i.e. factors at the patient-level, micro- (provider and social support), meso- (health care organization), and macro (health policy) -levels. In order to understand medication adherence and implement interventions to improve medication adherence, factors at these different levels should be taking into consideration. This paper describes an ecological model compromised of the most important factors at the patient-, micro-, meso- and macro-levels.

Prevalence and correlates of self-reported nonadherence with eye drop treatment: the Belgian Compliance Study in Ophthalmology (BCSO)

PURPOSE

This study aimed to investigate (1) the prevalence of nonadherence with eye drop treatment; (2) selected correlates of nonadherence at the patient and health-care organization level; and (3) the diagnostic value of the ophthalmologists' ratings, using patients' self-reports as standard.

METHODS

This cross-sectional multicenter survey used questionnaires for ophthalmologists and their patients to assess self-reported nonadherence and its correlates. One item, using a 4-point scale [never (ie, adherent) to daily], asked the patients whether they had forgotten to administer eye drops during the past 2 weeks. Ophthalmologists rated their patients as adherent or nonadherent. Nonadherence was also determined by combined methods, whereby either could indicate nonadherence. Given the nested structure of the data, multilevel modeling was used to investigate self-reported nonadherence-correlates. Diagnostic values of ophthalmologists' report were calculated.

RESULTS

Of 663 patients (48% female, 44% >69 years), nonadherence was indicated in 39.2% (n=260) through self-reporting, 2.1% (n=14) through ophthalmologists' ratings, and 40% (n=266) through combined measures. The multivariable, multilevel model showed following significant nonadherence-correlates: Male sex (P=0.01), younger age (P=0.027), and higher-dose frequency (P=0.001). No significant correlation with treating ophthalmologist (P=0.21) could be seen. Yet, the patients visiting their ophthalmologists at least every 3 months were less nonadherent than patients with fewer consultations (P=0.01). The ophthalmologists' report showed a sensitivity and specificity of 3% and 98.5%, respectively.

CONCLUSIONS

The prevalence of self-reported nonadherence was congruent with literature. The patients visiting their ophthalmologists at least every 3 months have a lower risk of nonadherence. Ophthalmologist report is an insensitive method for detecting nonadherence.

Interventions Used by Health Care Professionals to Enhance Medication Adherence in Transplant Patients: A Survey of Current Clinical Practice

Context

Although medication nonadherence is associated with severe complications including graft rejection and loss, its prevalence remains high among organ transplant recipients. Still, little information exists on clinical use of interventions to improve medication adherence.

Objective

To identify transplant health care professionals' methods of assessing medication adherence, classify the used interventions, and measure those interventions' perceived effectiveness.

Design, Setting and Participants

A 46-item questionnaire on adherence assessment and interventions was distributed at the 2010 International Transplant Nurses Society symposium in Germany. Data were analyzed by using descriptive statistics.

Results

Of 141 distributed questionnaires, 94 (67%) were returned. Respondents with no direct patient contact (9%, n = 8) were excluded. The most frequently used assessment strategy was patient self-reporting (60%, n = 52). On average, participants reported using 47% of the educational/cognitive, 44% of the counseling/behavioral, and 42% of the psychological/affective interventions listed. Training patients to self-administer medications and providing printed adherence information were the most frequently used interventions (79% each, n = 68), followed by providing printed medication instructions (69%, n = 59). Most respondents (90%, n = 77) reported combining interventions. The intervention perceived as most effective was medication self-administration training.

Conclusion

Although available alternatives are demonstrably more effective for enhancing medication adherence, this sample relied more on educational interventions.