Measuring patient-reported outcomes in solid organ transplant recipients: an overview of instruments developed to date

Associations between dialysis modality and adherence to immunosuppression after kidney transplantation-A single-center study

BACKGROUND

Patients with end-stage kidney disease often prefer home-based dialysis due to higher self-efficacy, which relates to improved medical treatment adherence. Kidney transplantation (KT) success depends on adhering to immunosuppressive medication post-transplant.

OBJECTIVES

To investigate whether adherence post-kidney transplantation (KT) and patients' attitudes toward immunosuppression were influenced by their prior dialysis type modality. Additionally, the study examined if adherence and patient's attitudes towards immunosuppression are associated with kidney graft survival.

METHODS

This cross-sectional single-center study included 201 KT patients. Adherence was assessed using BAASIS and the coefficient of variation of calcineurin inhibitors (COV-CNI). Patient attitudes towards medication were evaluated using the Q-method. Pill burden, comorbidity score and HRQoL and medication complexity, were scored. Cox regression was applied to determine KT survival outcomes over a 14-year follow-up period (until Dec 2021).

RESULTS

Prior dialysis modality was not associated with adherence to immunosuppression post-KT evaluated by BAASIS on average 4.7 years post-KT. Previous in-center hemodialysis patients had a higher CNI-COV (p = 0.011). The Q-sort analysis identified fully adherent patients linked to profile 1 (organized, resilient) whereas profile 2 patients were more careless. Patients linked to profile 3 (challenging, nervous) had higher education, a higher pill burden, and experienced more immunosuppression side effects. Death-censored graft loss increased by 7.6% with each additional pill, quadrupled if one dose of immunosuppression was missed, and increased by 2.9% for each point of COV-CNI rise.

CONCLUSIONS

Adherence to immunosuppression post-KT using BAASIS was not associated with prior dialysis type, despite in-center hemodialysis patients showing the highest COV-CNI. Taking COV-CNI into account, managing missed doses of immunosuppressants, and exploring patient attitudes could potentially enhance adherence and consequently improve KT survival.

Assessing quality of life in solid organ transplant recipients: A systematic review of the development, content, and quality of available condition- and transplant-specific patient-reported outcome measures

PURPOSE

We aimed to identify the condition- and transplant-specific patient-reported outcome measures (PROMs) available to measure quality of life (QoL) in solid organ transplant (SOT) recipients, examine their development and content, and critically appraise the quality of their measurement properties, to inform recommendations for clinical and research use.

METHODS

We systematically searched MEDLINE, Embase, CINAHL, PsycINFO, Cochrane CENTRAL, and Scopus from inception to 27th January 2023. Search hits were screened for eligibility by two independent reviewers; papers reporting the development and/or validation of condition- and transplant-specific PROMs measuring QoL in adult SOT recipients were considered eligible. We abstracted and synthesised data on PROM characteristics, development (item generation and/or reduction), and content (QoL dimensions). Quality appraisal and synthesis were informed by the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines, and included methodological and quality assessment of measurement properties, GRADE levels of evidence, feasibility and interpretability.

RESULTS

We identified 33 papers reporting 26 QoL PROMs validated in SOT recipients (kidney n = 10 PROMs; liver n = 6; lung n = 3; heart n = 2; pancreas n = 1; multiple organs n = 4). Patient discussions (n = 17 PROMs) and factor analysis (n = 11) were the most common item generation and reduction techniques used, respectively. All PROMs measured ≥3 of nine QoL dimensions (all measured emotional functioning); KDQoL-SF and NIDDK-QA measured all nine. Methodological quality was variable; no PROM had low evidence or better for all measurement properties. All PROMs were COSMIN recommendation category 'B', primarily because none had sufficient content validity.

CONCLUSIONS

There are many condition- and transplant-specific QoL PROMs validated in SOT recipients, particularly kidney. These findings can help inform PROM selection for clinicians and researchers. However, caution is required when adopting measures, due to the substantial heterogeneity in development, content, and quality. Each PROM has potential but requires further research to be recommendable. Greater consideration of patient and professional involvement in PROM development in this setting is needed to ensure sufficient content validity.

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review

OBJECTIVE

The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery.

METHODS

We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery.

RESULTS

We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%).

CONCLUSIONS

This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.

Instrumental activities of daily living in older patients with metastatic prostate cancer: results from the meet-URO network ADHERE prospective study

Instrumental activities of daily living (IADL) are significant health indicators closely related to executive functions and able to detect mild cognitive impairment. A decline in IADL usually precedes ADL limitation, including taking medications, and may therefore predict a cognitive decline. We aimed to investigate the association of patients' IADL score with other clinical factors, with a particular focus on the presence of a caregiver, and the impact on adherence to androgen receptor pathway inhibitors (ARPIs) and survival outcomes within the Meet-URO 5-ADHERE study. It was a large prospective multicentre observational cohort study monitoring adherence to ARPIs in 234 metastatic castrate-resistant PC (mCRPC) patients aged ≥ 70. We observed an association between impaired IADL and lower geriatric G8 scores (p < 0.01), and lower adherence to ARPIs whether assessed by pill counting (p = 0.01) or self-reported by the patient himself (p = 0.03). The combination of an IADL < 6 and the absence of a caregiver resulted in a significantly high risk of non-adherence to the ARPIs at the multivariable analysis (HR 9.23, 95% confidence interval 2.28-37.43, p = 0.01). IADL alongside the geriatric G8 scales represent essential tools to identify frail and less auto-sufficient patients who are extremely vulnerable particularly if not supported by a caregiver and have the highest risk of nonadherence to ARPIs.

Nonadherence to Immunosuppressants Among Transplant Recipients: Emotional Intelligence as a Predictive Factor During COVID-19 Pandemic

Purpose

To evaluate the association between emotional intelligence and fear of COVID-19 on self-reported adherence, based on a cross-sectional design.

Patients and Methods

Transplants recipient of both sexes aged 23-75 years old were evaluated at the Organ Transplant Unit, University Hospital of Catania, Italy. Data were analyzed using frequency, descriptives, Spearman and Pearson correlations, Chi-square goodness of fit test, and linear regression. Self-reported adherence was estimated with the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Emotional intelligence and fear of COVID were, respectively, measured with the Emotional Intelligence Scale (EIS) and Multidimensional Assessment of COVID-19 Related Fears Scale (MAC-RF). This was a cross-sectional study of kidney transplant recipients. In reporting this study the authors followed the STROBE guidelines.

Results

A correlation was found between EIS and MAC and between EIS and adherence but there was no correlation between MAC and adherence. A linear regression model was also conducted using a stepwise method, which indicated that EIS was a significant predictor of adherence (p <0.05).

Conclusion

This study was found that EIS is a predictor of adherence to treatment in transplant patients. Fear of COVID, while positively correlated to EIS, is not correlated to the adherence's outcome, possibly due to the proper follow-up performed to the patients. Indeed, according to these results, we suggest to provide good follow-ups with recipients, with interviews also based on self-regulation and awareness.

Novel Endpoints in Solid Organ Transplantation: Targeting Patient-reported Outcome Measures

Although solid organ transplantation improves survival and quality of life in many patients with organ failure, treatment complications and side effects can have debilitating consequences for patients. Patient-reported outcome measures (PROMs) capture how patients feel and function, including quality of life, symptoms, and side effects that are assessed directly by patients. Yet, they remain infrequently reported in trials in solid organ transplantation. Barriers to implementing PROMs in trials include uncertainty in selecting appropriate PROMs, concerns about resources limitations, patient burden, and limited evidence to support the psychometric robustness of measures for use in transplant recipients. In recent years, there have been increasing efforts to include patient-reported outcomes that are important to patients in trials to ensure that trials provide patient-centered information for decision-making. This article will provide an overview of PROMs, discuss PROs that are important to solid organ transplant recipients and those that are used in trials in solid organ transplantation, and outline approaches for selecting PROMs for clinical trials.

Adherence to Oral Treatments in Older Patients with Advanced Prostate Cancer, the ADHERE Study: A Prospective Trial of the Meet-URO Network

BACKGROUND

Novel androgen receptor signaling inhibitors for prostate cancer (PC) impose the burden of self-administration on older patients overwhelmed by the requirement of many other concomitant medications.

PATIENTS AND METHODS

This study evaluated the proportion of non-adherence in a 12-month follow-up period and the first 3 months to abiraterone (ABI) or enzalutamide (ENZ). In a prospective multicenter observational cohort study, patients with metastatic castration-resistant PC (mCRPC) aged ≥70 years receiving ABI or ENZ pre- or post-docetaxel were enrolled. Treatment monitoring included pill counting, a self-assessment questionnaire, and clinical diaries at each clinical visit. Non-adherence rates were based on proportions of missed/prescribed pills ratios by pill counting.

RESULTS

Overall, 234 patients were recruited with median age of 78 years (range, 73-82); 86 (37%) were treated with ABI, and 148 (63%) with ENZ. The median follow-up for adherence was seven monthly cycles (IQR: 4-12). The two cohorts were well balanced for baseline characteristics. The percentage of non-adherence by pill counting was slightly higher for ABI than ENZ (5.2% vs. 4.2%, P < .001). By self-reporting, patients on ENZ tended to report more frequently than those with ABI forgetfulness as the reason for missing events (42% vs. 17%, P < .001). A lower Geriatric G8 score correlated with non-adherence (P = .004). Overall survival (OS) was 48.8 months. Patients on ABI had radiographic progression-free survival (rPFS) of 28.4 [24.2-32.5], while for ENZ patients, we reported a median rPFS of 23.1 [18.2-28.1] months.

CONCLUSION

Physicians tend to treat older mCRPC patients with ENZ. Non-adherence rate is relatively low overall but can be higher with ABI than with ENZ and correlates with the Geriatric G8 score. Forgetfulness is a potential barrier for ENZ.

A systematic review of adherence to iron chelation therapy among children and adolescents with thalassemia

INTRODUCTION

Iron chelation therapy (ICT) is essential to prevent complications of iron overload in patients with transfusion-dependent thalassaemia. However, there is currently no standard for how to best measure adherence to ICT, nor what level of adherence necessitates concern for poor outcomes, especially in paediatric patients. The objectives of this review are to identify rates of adherence to ICT, predictors of adherence, methods of measurement, and adherence-related health outcomes in children and adolescents.

METHODS

This review covers the literature published between 1980 and 2020 on ICT in thalassaemia that assessed adherence or compliance. Included studies reflect original research. The preferred reporting items of systematic reviews and meta-analyses (PRISMA) guidelines were followed for reporting results, and the findings were critically appraised with the Oxford Centre for Evidence-based Medicine criteria.

RESULTS

Of the 543 articles, 37 met the inclusion criteria. The most common methods of assessing adherence included patient self-report (n = 15/36, 41.7%), and pill count (n = 15/36, 41.7%), followed by subcutaneous medication monitoring (5/36, 13.8%) and prescription refills (n = 4/36, 11.1%). Study sizes ranged from 7 to 1115 participants. Studies reported adherence either in "categories" with different levels of adherence (n = 29) or "quantitatively" as a percentage of medication taken out of those prescribed (n = 7). Quantitatively, the percentage of adherence varied from 57% to 98.4% with a median of 89.5%. Five studies focussed on interventions, four of which were designed to improve adherence. Studies varied in sample size and methods of assessment, which prohibited performing a meta-analysis.

CONCLUSIONS

Due to a lack of clinical consensus on how adherence is defined, it is difficult to compare adherence to ICT in different studies. Future studies should be aimed at creating guidelines for assessing adherence and identifying suboptimal adherence. These future efforts will be crucial in informing evidence-based interventions to improve adherence and health outcomes in thalassaemia patients.Key messagesPredictive factors associated with ICT adherence in the paediatric population include age, social perception of ICT, social support, and side effects/discomfort.Increased adherence in the paediatric population is associated with decreased serum ferritin and improved cardiac, hepatic, and endocrine outcomes.Inadequate adherence to ICT is associated with increased lifetime health costs.There are few studies that focussed on interventions to increase adherence in the paediatric population, and the studies that do exist all focussed on different types of interventions; successful interventions focussed on consistent, long-term engagement with patients.

Patient-reported outcomes evaluation and assessment of facilitators and barriers to physical activity in the Transplantoux aerobic exercise intervention

Background

Transplantoux’s MVT exercise intervention prepares organ transplant recipients to cycle or hike up France’s Mont Ventoux. We aimed to assess (i) MVT’s effects on patient-reported outcomes (PROs) and (ii) perceived barriers and facilitators to physical activity.

Methods

Using a hybrid design, a convenience sample of transplant recipients participating in MVT (n = 47 cycling (TxCYC); n = 18 hiking (TxHIK)), matched control transplant recipients (TxCON, n = 213), and healthy MVT participants (HCON, n = 91) completed surveys to assess physical activity (IPAQ), health-related quality of life (HRQOL; SF-36 and EuroQol VAS), mental health (GHQ-12), and depressive symptomatology, anxiety, and stress (DASS-21) at baseline, then after 3, 6 (Mont Ventoux climb), 9, and 12 months. TxCYC and TxHIK participated in a 6-month intervention of individualized home-based cycling/hiking exercise and a series of supervised group training sessions. Barriers and facilitators to physical activity (Barriers and Motivators Questionnaire) were measured at 12 months.

Results

Regarding PROs, except for reducing TxHIK stress levels, MVT induced no substantial intervention effects. For both TxCYC and TxHIK, between-group comparisons at baseline showed that physical activity, HRQOL, mental health, depressive symptomatology and stress were similar to those of HCON. In contrast, compared to TxCYC, TxHIK, and HCON, physical activity, HRQOL and mental health were lower in TxCON. TxCON also reported greater barriers, lower facilitators, and different priority rankings concerning physical activity barriers and facilitators.

Conclusion

Barely any of the PROs assessed in the present study responded to Transplantoux’s MVT exercise intervention. TxCON reported distinct and unfavorable profiles regarding PROs and barriers and facilitators to physical activity. These findings can assist tailored physical activity intervention development.

Trial registration

Clinical trial notation: The study was approved by the University Hospitals Leuven’s Institutional Review Board (B322201523602).

Health-related quality of life and psychological indicators of thriving 15-19 years after heart or lung transplantation

BACKGROUND

Survival into the second decade after cardiothoracic transplantation (CTX) is no longer uncommon. Few data exist on any health-related quality of life (HRQOL) impairments survivors face, or whether they may even experience positive psychological outcomes indicative of "thriving" (e.g., personal growth). We provide such data in a long-term survivor cohort.

METHODS

Among 304 patients prospectively studied across the first 2 years post-CTX, we re-interviewed patients ≥15 years post-CTX. We (a) examined levels of HRQOL and positive psychological outcomes (posttraumatic growth related to CTX, purpose in life, life satisfaction) at follow-up, (b) evaluated change since transplant with mixed-effects models, and (c) identified psychosocial and clinical correlates of study outcomes with multivariable regression.

RESULTS

Of 77 survivors, 64 (83%) were assessed (35 heart, 29 lung recipients; 15-19 years post-CTX). Physical HRQOL was poorer than the general population norm and earlier post-transplant levels (P's < .001). Mental HRQOL exceeded the norm (P < .001), with little temporal change (P = .070). Mean positive psychological outcome scores exceeded scales' midpoints at follow-up. Life satisfaction, assessed longitudinally, declined over time (P < .001) but remained similar to the norm at follow-up. Recent hospitalization and dyspnea increased patients' likelihood of poor physical HRQOL at follow-up (P's ≤ .022). Lower sense of mastery and poorer caregiver support lessened patients' likelihood of positive psychological outcomes (P's ≤ .049). Medical comorbidities and type of CTX were not associated with study outcomes at follow-up.

CONCLUSIONS

Despite physical HRQOL impairment, long-term CTX survivors otherwise showed favorable outcomes. Clinical attention to correlates of HRQOL and positive psychological outcomes may help maximize survivors' well-being.

Comparison of out-of-pocket costs and adherence between the two arms of the prospective, randomized abiraterone food effect trial

PURPOSE

Abiraterone acetate, prescribed for metastatic prostate cancer, has enhanced absorption with food. This effect was exploited in a randomized trial which showed noninferiority of PSA decline for 250 mg abiraterone with a low-fat meal (LOW) compared to 1,000 mg abiraterone fasting (STD). Drug was obtained via patient insurance. Patient out-of-pocket costs and adherence were surveyed.

METHODS

Trial participants were randomized to STD or LOW, and surveys of adherence and out-of-pocket costs were administered at baseline and just before coming off study (follow-up).

RESULTS

Out-of-pocket costs were available from 20 of 36 STD and 21 of 36 LOW patients. Median out-of-pocket costs for a month of drug were $0 (LOW) and $5 (STD); mean costs were $43.61 (LOW) and $393.83 (STD). The two groups did not differ significantly (p = 0.421). Maximum out-of-pocket cost was $1,000 (LOW) and $4,000 (STD). Monthly out-of-pocket costs > $500 were found in 1 LOW and 5 STD patients. For adherence, only 11 STD and 19 LOW patients had questionnaires completed at both baseline and follow-up. STD adherence was 98.18% at baseline and 91.69% at follow-up, differing significantly (p = 0.0078). LOW adherence was 96.52% at baseline and 97.86% at follow-up, not differing significantly (p = 0.3511). Adherence did not correlate with demographics. At follow-up, increasing adherence correlated significantly with decreasing dose (p = 0.013; rho =  - 0.458).

CONCLUSIONS

Out-of-pocket costs did not differ significantly in this limited analysis. Adherence was significantly different in STD as the trial progressed, which was not found in LOW.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01543776; registered March 5, 2012.

Creation of an electronic patient-reported outcome measure platform Voxe: a mixed methods study protocol in paediatric solid organ transplantation

INTRODUCTION

Patient-reported outcome measures (PROMs) provide an opportunity for meaningful patient engagement and shared decision-making. The objective of this research programme is to improve health outcomes for paediatric solid organ transplant patients by implementing PROMs into clinical care. The current study aims to create Voxe, a paediatric user-centred electronic PROM platform, by engaging patients and healthcare providers throughout the design and development process.

METHODS AND ANALYSIS

The creation of Voxe will occur over two phases that build on previous research. The user interface design phase employs a 'user-centric' approach to identify end-users' needs and iteratively refine the look and layout of Voxe to meet these needs. Transplant recipients, aged 10-17, and healthcare providers will participate in three rounds of testing (24 participants total). Participants will: (1) complete task-based activities (outcomes-effectiveness and efficiency), (2) complete questionnaires (outcome-satisfaction) and (3) participate in a semi-structured interview. The following phase involves software development and Voxe usability testing. Transplant recipients, aged 8-17, and healthcare providers will participate in four rounds of iterative testing (24-40 participants total). The think-aloud technique will be employed, and participants will describe their thoughts and feelings while interacting with a Voxe prototype. Participants will: (1) log into Voxe and complete tasks (outcomes-time on task, successful task completion, frequency of critical and non-critical errors and error-free rate), (2) complete questionnaires (outcome-satisfaction) and (3) participate in a semi-structured interview. Findings will result in the creation and launch of a user-centred electronic PROM platform.

ETHICS AND DISSEMINATION

Research ethics board approval has been provided by The Hospital for Sick Children. This research is critical to answering methodological and operational questions to inform Voxe implementation in paediatric clinical settings and facilitate PROM data collection. Future investigations will include an implementation-effectiveness evaluation.

Immunologic Abnormalities Associated With Health Status of Heart Recipients Long Term After Transplantation

BACKGROUND

With improvements in survival rates, health-related quality of life is an important outcome parameter to evaluate the effectiveness of transplantation. We aimed to identify potential immunologic abnormalities as factors associated with poorer health-related quality of life at distinct scales of the 36-Item Short Form Health Survey in heart transplant recipients long term after transplantation.

METHODS

One hundred heart transplant recipients were evaluated in a single center. Short-form 36 questionnaires were sent by mail to participants. All patients were clinically and immunologically evaluated after the first year of heart transplantation.

RESULTS

A high prevalence of several immunologic abnormalities persisted even after the first year of transplantation, including IgG hypogammaglobulinemia, low IgG-specific antipneumococcal antibodies, C4 hypocomplementemia, CD8 T-cell lymphocytopenia, and CD19 B-cell lymphocytopenia. Older recipients (>55 years), posttransplant diabetes, digestive complications, and posttransplant infections were associated with lower physical functioning scores (scale < 60). Older recipients (>55 years), pretransplant diabetes, pretransplant arterial hypertension, posttransplant digestive complications, and lower CD8 counts were associated with lower physical role scores (scale <25).

CONCLUSION

In a single center study, lower CD8 cell counts were found to be associated with poorer health status in heart recipients after the first year of transplantation.

Is simplification of immunosuppressive medication a way to promote medication adherence of kidney transplant recipients? Findings from a randomized controlled trial

After kidney transplantation, a strict immunosuppressive medication regimen is necessary for graft survival. However, nonadherence to medication has been shown to occur early after transplantation and to increase over time. Weaning the recipient off dual therapy onto monotherapy in order to reduce immunosuppressive burden may also be a way to promote adherence, although little is known about the impact of such a regimen on fear of rejection. We performed a cohort study on medication adherence and fear of rejection in a randomized, investigator‐driven, open‐label, single‐centre pilot study. Recipients were randomized at 6‐months post‐transplant to either continue Tacrolimus and Mycophenolate mofetil (TAC/MMF) or to taper MMF at 6 months and discontinue MMF at 9 months (TAC monotherapy). Recipients completed questionnaires about medication adherence and fear of rejection at 6 and 12‐months post‐transplantation. Medication adherence was significantly higher in the TAC monotherapy group compared to dual TAC/MMF therapy group (χ² (1) = 4.582; P = 0.032). We found no difference in fear of rejection between the two groups of recipients (P = 0.887). Simplification of the medication regimen is a potential tool for increasing adherence in clinical practice (Netherlands Trial Register – NL4672).

Using a novel concept to measure outcomes in solid organ recipients provided promising results

OBJECTIVES

Efforts to evaluate the health of solid organ transplant recipients are hampered by the lack of adequate patient-reported outcome measures (PROMs) targeting this group. We developed the Transplant ePROM (TXP), which is based on a novel measurement model and administered through a mobile application to fill this gap. The main objective of this article is to elucidate how we derived the weights for different items, and to report initial empirical results.

STUDY DESIGN AND SETTING

The nine health items in the TXP were fatigue, skin, worry, self-reliance, activities, weight, sexuality, stooling, and memory. Via an online survey solid organ recipient participating in the TransplantLines Biobank and Cohort study (NCT03272841) were asked to describe and then compare their own health state with six other health states. Coefficients for item levels were obtained using a conditional logit model.

RESULTS

A total of 232 solid organ transplant recipients (mean age: 54 years) participated. The majority (106) were kidney recipients, followed by lung, liver, and heart recipients. Fatigue was the most frequent complaint (54%). The strongest negative coefficients were found for activities and worry, followed by self-reliance and memory.

CONCLUSION

A set of coefficients and values were developed for TXP. The TXP score approximated an optimal health state for the majority of respondents and recipients of different organs reported comparable health states.

Retrospective Analysis of Tacrolimus Intrapatient Variability as a Measure of Medication Adherence

Background:

Increased intrapatient variability (IPV) in tacrolimus levels is associated with graft rejection, de novo donor-specific antibodies, and graft loss. Medication nonadherence may be a significant contributor to high IPV.

Objective:

The objective of this study is to determine the utility of tacrolimus IPV in detecting nonadherence by examining the relationship between self-reported adherence and tacrolimus coefficient of variability (COV), a measure of IPV.

Design:

Retrospective cohort study.

Setting:

St. Michael’s Hospital, Toronto, Ontario.

Patients:

All patients who were at least 1-year post-kidney transplant as of March 31, 2019, prescribed tacrolimus as an immunosuppressant and had a self-reported adherence status. Patients were excluded from the primary analysis of examining the correlation between COV and self-reported adherence if they lacked a calculatable COV.

Measurements:

Self-reported adherence, COV, demographic data, transplant, and medication history.

Methods:

A modified Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) administered by healthcare professionals to assess self-reported adherence was used. The COV of tacrolimus trough levels was calculated and its correlation to BAASIS response was noted. The median COV was used as a cutoff to examine the characteristics of patients deemed “high COV” and “low COV.”

Results:

A total of 591 patients fit the initial criteria; however, only 525 had a recent calculatable COV. Overall, 92.38% of the population were adherent by self-report. Primary analysis identified a COV of 25.2% and 29.6% in self-reported adherent and nonadherent patients, respectively, though the result was not significant (P = .2). Secondary analyses showed a significant correlation between younger age at transplant and at the time of adherence self-reporting with nonadherence (P = .01). In addition, there was a strong correlation between those nonadherent with routine post-transplant blood work and younger age (P < .01).

Limitations:

The limitations included modified nonvalidated BAASIS questionnaire, social desirability bias, BAASIS only administered in English, and patients with graft failure not active in clinic not being captured.

Conclusions:

The COV should not be used as the sole method for determining medication adherence. However, COV may have some utility in capturing individuals who are not adherent to their blood work or patients who are having a poor response to tacrolimus and should be switched to another medication.

Adherence in pediatric renal recipients and its effect on graft outcome, a single-center, retrospective study

BACKGROUND

In recent years, treatment-adherence gained increasing attention in nearly every area of medicine including transplant medicine. Medication adherence following solid organ transplantation is known to be indispensable for a satisfactory allograft survival.

METHODS

We examined 60 patients between the ages of four months and 20 years who underwent kidney transplantation at Hannover Medical School between January 2011 and August 2017. Age at transplantation varied from 4 months to 20 years. 12 patients (20%) already underwent their second solid organ transplantation. 5 patients (8.3%) had a combined kidney-liver-transplantation. We used two different methods for rating adherence: An objective one based on the coefficient of variation (CoV%) of immunosuppressant trough levels, and a subjective questionnaire answered by the patients themselves, their parents or legal custodians, the treating pediatrician, as well as by the attending psychologist.

RESULTS

The CoV% in our study was by-trend higher in those patients who suffered from a biopsy-proven rejection (x̅_CoV% = 35.7, σ _CoV% = 30.1 in patients with rejection vs. x̅ _CoV% = 26.0, σ _CoV% = 10.5 in patients without rejection). Furthermore, the psychologist's assessment correlated significantly both with rejections as well as with the formation of de novo donor-specific antibodies (dnDSA) while the pediatrician's rating showed no correlation (P_rejections  = 0.005 and P_dnDSA  = 0.03 for psychologist's rating vs. P_rejections  = 0.50 and P_dnDSA  = 0.50 for pediatrician).

CONCLUSIONS

Apart from underlining the importance of medication adherence, the present research stresses the role of a multi-disciplinary treatment approach to support pediatric renal transplant recipients and their families.

Patient-reported outcome measures in pediatric solid organ transplantation: Exploring stakeholder perspectives on clinical implementation through qualitative description

PURPOSE

Patient-reported outcome measures (PROMs) are standardized instruments used to collect data about the subjective assessment of medical care from the patient perspective. Implementing PROMs within pediatric clinical settings has gained increasing importance as health services prioritize patient-centred pediatric care. This study explores the perspectives of pediatric solid organ transplant patients, caregivers, and healthcare practitioners (HCPs) on implementing PROMs into clinical practice.

METHODS

Qualitative description methods were used to elicit stakeholder perspectives. Semi-structured interviews were conducted across five Canadian transplant centres. Purposive sampling was used to obtain maximum variation across age, gender, and transplant program for all participants, as well as discipline for HCPs.

RESULTS

The study included a total of 63 participants [patients (n = 20), caregivers (n = 22) and HCPs (n = 21)]. Nearly all participants endorsed the implementation of PROMs to enhance pediatric transplant clinical care. Three primary roles for PROMs emerged: (1) to bring a transplant patient's overall well-being into the clinical care conversation; (2) to improve patient communication and engagement; and, (3) to inform the practice of clinical pediatric transplant care. Insights for effective implementation included completing electronic PROMs remotely and prior to clinical appointments by patients who are eight to 10 years of age or older.

CONCLUSIONS

This study contributes to current research that supports the use of PROMs in clinical pediatric care and guides their effective implementation into practice. Future directions include the development, usability testing, and evaluation of a proposed electronic PROM platform that will inform future research initiatives.

Symptom Experience and Related Predictors in Liver Transplantation Recipients

PURPOSE

Symptom experience after liver transplantation (LT) provides healthcare professionals with important information about the benefits and limitations of LT from patients' perspective. This study aims to explore the multidimensional symptom experience and analyze related predictive factors in LT recipients.

METHODS

This cross-sectional study evaluated the occurrence, frequency, intensity, and level of distress of 40 symptoms in 265 LT recipients. Stepwise multiple regression analysis was performed to analyze the influencing factors of symptom experience.

RESULTS

The analysis of patient-reported data indicated that the ten most common symptoms were fatigue (42.3%), frequent sleep interruptions (38.9%), difficulty falling asleep (35.9%), decreased memory (34.0%), dreaminess (29.8%), itch (28.7%), muscular weakness (26.4%), shortness of breath (25.3%), anxiety (24.5%), and hand tremor (21.9%). Patients were classified into four groups according to survival time (1-month, 2-6-month, 7-12-month, and >1-year groups) after LT, and the most common symptom was fatigue in the one-month and 2-6-month groups, difficulty falling asleep in the 7-12-month group, and decreased memory in the >1-year group. Type of the primary caregiver, complications, concerns about the decreased ability to perform household and outdoor activities, and concerns about being a burden to the family were predictors of symptoms burden.

CONCLUSION

LT recipients experienced complicated symptoms. In clinical practice, it is critical to integrate physicians, nurses, and social workers as a medical team to help LT recipients develop suitable coping strategies that can potentially address patients' concerns, increase the sense of confidence, and improve symptom outcomes.

Questionnaires assessing the use of complementary health approaches in pediatrics and their measurement properties: A systematic review

OBJECTIVES

To identify questionnaires assessing the use of complementary health approaches (CHA) in pediatrics, describe their content, and appraise the methodological quality of the studies and the measurement properties of the questionnaires.

METHOD

Major electronic databases were searched from 2011 to 2020. Studies which aimed to assess the use of CHA and studies which reported developing and validating CHA questionnaires in pediatrics were included. Two reviewers independently screened the studies, extracted the data, and rated the methodological quality of the studies and measurement properties of the questionnaires using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. When consensus was not reached, a third reviewer was consulted.

RESULTS

Thirty-eight studies were included. From these studies, 35 CHA questionnaires with a variety of different items were identified. Only two studies aimed to evaluate the measurement properties of two questionnaires. One questionnaire, available as a self- and proxy-report, was initially validated in children with juvenile idiopathic arthritis, and the other, available as an interviewer-administered questionnaire, was validated in children with cancer. According to the COSMIN, the methodological quality of both studies was inadequate or doubtful, and both questionnaires was not thoroughly validated.

CONCLUSION

This systematic review showed a lack of a thoroughly validated CHA questionnaire in pediatrics. However, two questionnaires were found to hold promise. To address this gap, one of the existing questionnaires should be adapted and further validated.

Adherence to abiraterone or enzalutamide in elderly metastatic castration-resistant prostate cancer

PURPOSE

To evaluate adherence to abiraterone or enzalutamide for the treatment of metastatic castration-resistant prostate cancer (mCRPC).

METHODS

In an observational prospective cohort study, we monitored patients with mCRPC for their adherence to abiraterone or enzalutamide in the pre- or post-chemotherapy setting.

RESULTS

Fifty-eight patients with median age of 76 years (range 56-94), age-adjusted Charlson comorbidity score of 10 (range, 4-15), and geriatric G8 score of 14 (range, 6-17) were enrolled. Twenty-two (38%) patients were treated with abiraterone and 36 (62%) with enzalutamide, while forty-two (72%) were in the pre-chemotherapy setting. Forty-seven patients (81%) had a caregiver. Based on the pill counting, a non-adherence rate of 4.8% and 6.2% was observed for the whole period and the first 3 months, respectively, without a statistically significant difference between abiraterone and enzalutamide cohorts. A lower non-adherence rate (1.3%) was reported by patients during the whole period, mainly due to a misperception (77%) and forgetfulness (19%). Non-adherence rate to the fulfilling of the clinical diary was 38% for the whole period. Non-adherence in the whole period was related to the radiological response (p = 0.03) and geriatric G8 score (p = 0.005). By the receiver operating characteristic (ROC) curve based on the radiological response, non-adherence cut-off was 1.87% (p = 0.04). By this non-adherence cut-off, the G8 cut-off was 14.75 (p = 0.0003).

CONCLUSION

Non-adherence to abiraterone or enzalutamide for mCRPC may have an impact on disease response and be related to patients' frailty, suggesting their geriatric assessment and clinical interventions to monitor and increase their adherence.

A Review of the Prevalence of Illicit Substance Use in Solid-Organ Transplant Candidates and the Effects of Illicit Substance Use on Solid-Organ Transplant Treatment Outcomes

Solid-organ transplantation is one of the significant advances in the medical field that have improved the quality of life and survival rates of numerous patients with end-organ dysfunction. Substance use is a common condition of individuals who are in need of solid-organ transplantation. The implications of substance use on solid-organ transplants are gaining increasing attention over the past decade. The current review seeks to explore the prevalence rate of illicit substance use among those who receive solid-organ transplantation (pre and post-transplant) and whether illicit substance use before solid-organ transplantation affects the outcome of solid-organ transplants. We searched the Medline database for all the articles available in English on the prevalence of substance use in the context of solid-organ transplant and the effect on outcome measures. We found 21 relevant articles. It appears that substance use is fairly common among solid-organ transplant candidates, with cannabis being the most common substance of abuse. A heterogeneous sample precludes the drawing of a clear-cut conclusion. But it appears that substance use may affect various outcomes of solid-organ transplants. The existing literature may not be sufficient to adequately assess the risk but limited evidence indicates that illicit substance use, particularly cannabis use, may not affect the overall survival following a solid-organ transplant.

Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Medication Adherence Scale (PMAS)

Poor medication adherence is associated with reduced drug effectiveness, poor health-related quality of life, increased morbidity and mortality, and increased healthcare utilization and cost. Including the patient's voice is essential in understanding barriers to adherence. Useful patient-reported adherence measures are brief, inexpensive, non-invasive; can indicate barriers to adherence; and can be incorporated in electronic health records. The NIH Patient-Reported Outcomes Measurement Information System (PROMIS^®) includes high-quality, freely available patient-reported measures covering many important constructs in patient-centered research but does not include a medication adherence measure. To fill this gap, we developed the PROMIS Medication Adherence Scale (PMAS) using the rigorous PROMIS instrument development guidelines. To develop the PMAS, we first conducted a review of the reviews, which enabled us to identify content areas relevant to medication adherence behavior. Then, we conducted qualitative research to elicit patients' views of and experiences with medication adherence. This process identified the following important content areas to guide item writing: extent medication is taken, knowledge of medication regimen, beliefs about medication, remembering to take medication, skipping due to side effects, skipping due to feeling better, and cost of medications. Based on the results of these activities, we wrote items and aimed to retain 1-2 items per content area. The final item set included 9 total adherence items, which were then refined through intensive comprehension and translatability review, as well as cognitive interviews. Future steps include testing the PMAS's validity.

Patient-reported outcome measures within pediatric solid organ transplantation: A systematic review

Subjective evaluation of medical care and disease outcomes from patients' perspectives has become increasingly important. Patient-reported outcome measures (PROMs) play a prominent role in engaging patients, capturing their experiences and improving patient care. This systematic review sought to identify PROMs that are used in the field of pediatric solid organ transplantation, with the aim to inform the implementation of PROMs into clinical practice for this population. A systematic review of English language, peer-reviewed articles was performed on key health science databases to identify publications using PROMs in pediatric solid organ transplantation. The search yielded 3670 articles, with a final data set of 62 articles that included 47 different PROMs. The three most frequently used PROMs included the following: (a) PedsQL™ Generic Core Scales (n = 25); (b) Children's Depression Inventory (n = 6); and (c) Child Health Questionnaire (n = 6). Of the 47 PROMs, 42 were generic and five were disease-specific; only six PROMS had a documented psychometric evaluation within a pediatric solid organ transplant population. This review outlines the attributes of the instruments (eg, domains captured), as well as the psychometric properties of those evaluated. PROMs are increasingly used in the field of pediatric transplantation; however, there are limited details in the current literature about their conceptual underpinnings and psychometric properties. This review highlights the need for additional psychometric evaluation of identified measures to establish the necessary foundation to inform the implementation of PROMs into clinical care for pediatric solid organ transplant patients.

A Scoping Review of Key Health Items in Self-Report Instruments Used Among Solid Organ Transplant Recipients

The overall aim of this scoping review of the literature is twofold: (1) to provide an overview of all instruments that have been used to assess health-related quality of life (HRQoL) after solid organ transplantation and (2) to provide a list of health items they include to support future studies on the development of a new-generation HRQoL instrument. All studies that administered any form of HRQoL instrument to post-transplant solid organ recipients were identified in a comprehensive search of PubMed (MEDLINE), Embase, and Web of Science, with a cut-off date of May 2018. The search used various combinations of the following keywords: lung, heart, liver, kidney, or pancreas transplantation; quality of life; well-being; patient-reported outcome; instrument; questionnaire; and health survey. In total, 8013 distinct publications were identified and 1218 of these were selected for review. Among the instruments applied, 53 measured generic, 51 organ-specific, 271 domain-specific, and 43 transplant-specific HRQoL. A total of 78 distinct health items grouped into 16 sub-domains were identified and depicted graphically. The majority of publications did not report a logical rationale for the choice of specific HRQoL instrument. The most commonly used types of instruments were generic health instruments, followed by domain-specific instruments. Despite the availability of transplant-specific instruments, few studies applied these types of instruments. Based on the 78 items, further research is planned to develop a patient-centered, transplant-specific HRQoL instrument that is concise, easy to apply (mobile application), and specifically related to the health issues of solid organ recipients.

Prevalence of Medication Nonadherence to Co-medication Compared to Immunosuppressants in Heart Transplant Recipients: Findings From the International Cross-sectional BRIGHT Study

PURPOSE

To assess and compare the prevalence of medication nonadherence (MNA) (implementation and persistence) to immunosuppressants and co-medications in heart transplant recipients.

METHODS

MNA prevalence was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (self-report) and compared using logistic regression in a 4-continent sample of 1397 heart transplant recipients from 36 heart transplant centers in 11 countries.

FINDINGS

MNA was significantly (α = 0.05) higher to co-medications than to immunosuppressants (taking nonadherence: 23.9% vs 17.3%; odds ratio [OR] = 1.5; 95% CI, 1.30-1.73; drug holiday: 5.7% vs 1.9%; OR = 3.17; 95% CI, 2.13-4.73; dose alteration: 3.8% vs 1.6%; OR = 2.46; 95% CI, 1.49-4.06; and discontinuation: 2.6% vs 0.5%; OR = 5.15; 95% CI, 2.36-11.20).

IMPLICATIONS

The observed MNA necessitates adherence-enhancing interventions encompassing the entire post-heart transplant medication regimen. ClinicalTrials.gov identifier: NCT01608477.

Self-management in liver transplantation

BACKGROUND

Self-management is crucial for liver transplant (LT) recipients to maintain transplants and optimize health outcomes. However, previous literature has been primarily limited to examining medication adherence; there is a knowledge gap regarding self-management in the LT population.

AIM

The aims of this study were to 1) comprehensively describe self-management behaviors and activities in LT recipients, 2) explore levels of overall self-management, and 3) explore the relationships of self-efficacy, cognition, and health information seeking behavior with self-management.

METHODS

Adult LT recipients (n = 113) who had a functioning transplant for at least 6 months participated in this cross-sectional, descriptive study. Participants were asked to identify self-management behaviors and rate their performance of those behaviors, including symptom management and medication adherence. They also completed a cognitive assessment and questionnaires measuring self-efficacy and health information seeking behavior. Descriptive statistics, latent profile analysis, and probit model for path analysis were used for the data analysis.

RESULTS

LT recipients acknowledged engaging in various self-management behaviors including symptom management, physical activity, maintenance of positive attitudes, and communication with healthcare providers. Three levels of self-management (i.e., low, medium, and high) were found; a high level of self-management was related to self-efficacy and health information seeking behavior.

CONCLUSIONS

The findings indicate that self-management may be improved with interventions aimed at increasing self-efficacy and health information seeking behavior. Findings from this study will inform future interventions, to improve self-management and subsequent health outcomes in this population. Future longitudinal studies are necessary to confirm the causality of the identified relationships.

Identifying Tyrosine Kinase Inhibitor Nonadherence in Chronic Myeloid Leukemia: Subanalysis of TAKE-IT Pilot Study

BACKGROUND

There are inconsistencies in reports on correlates for nonadherence (NA) to tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML). The diagnostic accuracy of subjective adherence measures using electronic monitoring (EM) as the reference standard is yet to be determined. This study aimed to evaluate correlates of TKI NA using EM and test the diagnostic accuracy of subjective adherence measures.

PATIENTS AND METHODS

CML patients receiving a TKI for any duration were enrolled at 4 hematology institutes, and adherence was measured for 4 months. EM adherence was the reference adherence measure, expressed as the percentage of days with the drug taken as prescribed. Subjective adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) self-report and clinician-reported visual analog scale (VAS) at 2 time points. Baseline theory-derived correlates of NA were identified using single and multiple regression analysis. The diagnostic accuracy of BAASIS and clinician-reported VAS was tested against an exploratory EM NA cutoff of < 95%.

RESULTS

The median EM adherence (n = 55) was 97.5% (range, 48-100%), while the 25th percentile was 92.1%. Lack of membership in a CML patient support group, living alone, and third-line treatment were associated with EM NA on multiple regression analysis. The BAASIS self-report (n = 94) had a sensitivity of 67% and a specificity of 71% for diagnosing NA, while clinician-reported VAS (n = 89) had a sensitivity of 78% and specificity of 42%.

CONCLUSION

A quarter of patients had potentially clinically meaningful NA. These NA correlates and the BAASIS provide a basis for identifying nonadherent patients who can be targeted by interventions.

Adherence and Coping Strategies in Outpatients With Chronic Myeloid Leukemia Receiving Oral Tyrosine Kinase Inhibitors

PURPOSE/OBJECTIVES

To assess adherence and coping strategies in outpatients with chronic myeloid leukemia (CML) on oral tyrosine kinase inhibitors (TKIs).
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DESIGN

Prospective, descriptive.
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SETTING

An interdisciplinary oncology outpatient clinic in Germany.
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SAMPLE

35 outpatients with CML on oral TKIs.
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METHODS

Adherence and coping strategies were assessed with questionnaires. Clinical data were extracted from medical charts.
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MAIN RESEARCH VARIABLES

Adherence rates, main coping strategies, and frequency and contents of single coping strategies.
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FINDINGS

18 patients showed adherence according to the applied screening instrument. Main coping strategies were spirituality and search for meaning. The two single items most frequently specified were adhering to medical instructions and trusting in the medical personnel involved.
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CONCLUSIONS

The low adherence rate of 51% most likely resulted from using the Basel Assessment of Adherence Scale as the questionnaire of choice. The relevance of spirituality and search for meaning as main coping strategies has not been shown previously in outpatients with CML. Most patients wish to obey medical instructions accurately and put trust in their oncologists; this introduces a resource that should gain relevance considering the increasing number of oral anticancer drugs.
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IMPLICATIONS FOR NURSING

Nurses are encouraged to routinely assess adherence and spiritual needs in outpatients with CML. Spirituality and search for meaning represent pivotal coping strategies in this group, which has an excellent prognosis. Oncology nurses may help provide tailored support, thereby ameliorating care for these patients.

National Trends and In-Hospital Outcomes of Patients With Solid Organ Transplant Undergoing Spinal Fusion

STUDY DESIGN

A retrospective analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample.

OBJECTIVE

To examine the demographics and in-hospital outcomes of patients with solid organ transplant (SOT) undergoing spinal fusion on a national level.

SUMMARY OF BACKGROUND DATA

Solid organ transplantation has become more common in recent years and some of these patients undergo spinal fusion surgery. There is, however, little information regarding the trends and outcomes in such patients.

METHODS

Clinical data were derived from the US Nationwide Inpatient Sample between 2000 and 2009. Patients with or without SOT who underwent spinal fusion were identified. Data regarding, patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved and analyzed. In-hospital outcomes were compared between patients with or without SOT and analyzed with the use of multivariate logistic regression.

RESULTS

A total of 5984 patients with SOT underwent spinal fusion in the United States during the last decade. From 2000 to 2009, population growth-adjusted incidence of patients with SOT who underwent spinal fusion has increased more than two fold (0.102 in 2000 to 0.236 in 2009, per 100,000, P < 0.001). Comparison between patients with or without SOT showed that patients with SOT had significantly higher overall in-hospital complication rate (22.4% vs. 9.5%) and in-hospital mortality rate (1.3% vs. 0.3%). Graft versus host disease occurred in 0.7% of patients with SOT undergoing spinal fusion. Patients with SOT had a significant higher risk of urinary and renal complications and overall in-hospital complications.

CONCLUSION

During the last decade, the incidence of patients with SOT undergoing spinal fusion has increased in the United States. In-hospital outcomes of patients with SOT undergoing spinal fusion were inferior to those of patients without SOT.

LEVEL OF EVIDENCE

3.

Clinical Evaluation of Modified Release and Immediate Release Tacrolimus Formulations

The science of drug delivery has evolved considerably and has led to the development of multiple sustained release formulations. Each of these formulations can present particular challenges in terms of clinical evaluation and necessitate careful study to identify their optimal use in practice. Tacrolimus is an immunosuppressive agent that is widely used in organ transplant recipients. However, it is poorly soluble, has an unpredictable pharmacokinetic profile subject to important genetic polymorphisms and drug-drug interactions, and has a narrow therapeutic index. For these reasons, it represents an agent that could benefit from modified release formulations to overcome these limitations. The objective of this review is to discuss the clinical evaluation of immediate and modified release tacrolimus formulations in renal transplant recipients. Clinical trials from early development of immediate release tacrolimus to formulation-specific post-marketing trials of modified release tacrolimus formulations are reviewed with an emphasis on key elements relating to trial design end endpoint assessment. Particular elements that can be addressed with formulation alterations, such as pharmacokinetics, pharmacogenomics, and toxicity and corresponding clinical evaluations are discussed. In addition, current knowledge gaps in the clinical evaluation of immediate and modified release tacrolimus formulations are discussed to highlight potential avenues for the future development of different tacrolimus formulations with outcomes relevant to the regulators, the transplant community, and to transplant recipients. This review shows that new formulations may alter tacrolimus bioavailability, alleviate certain adverse events while potentially enhancing patient convenience.

Outcomes in randomized controlled trials of exercise interventions in solid organ transplant

AIM

To identify the outcome measures that have been used in randomized controlled trials (RCTs) of exercise training in solid organ transplant (SOT) recipients and to link these outcomes to the International Classification of Functioning, Disability and Health (ICF) framework.

METHODS

Electronic literature searches of MEDLINE, EMBASE, CINAHL, Cochrane, Scopus, and Web of Science were performed. We sought RCTs that investigated the effect of exercise training in SOT recipients. Reference lists of all eligible publications were searched for other appropriate studies not identified by the electronic search. A complete list of outcome measures used in the RCTs was generated and each of these was linked to an ICF category.

RESULTS

Four hundred and thirteen articles were retrieved, of which 35 met our inclusion criteria. The studies included were designed to compare the effects of exercise training programs to usual care or to another exercise training program and reported on recipients of heart (n = 21), kidney (n = 9), lung (n = 3) or liver (n = 2) transplant. Of the 126 outcome measures identified, 62 were used as primary outcome measures. The most commonly occurring primary outcomes were aerobic capacity using the peak VO₂ (n = 13), quality of life using the short-form-36 (n = 8), and muscle strength (n = 7). These outcome measures were linked to 113 ICF categories and the majority of outcomes fall into the body function domain (n = 93).

CONCLUSION

There is little standardization in outcome measures used in RCTs of exercise interventions in SOT recipients. The ICF framework can be used to select a core set of outcomes that cross all domains of ICF and that would be appropriate to all SOT recipients.

Patient engagement impacts glycemic management with vildagliptin and vildagliptin/metformin (single pill) regimens in type 2 diabetes mellitus (the GLORIOUS study)

AIMS

To evaluate the real-world effectiveness of vildagliptin and vildagliptin/metformin, combined with patient engagement, on glycemic outcomes. Patient engagement included both clinicians' engaging patients through education and counseling; and patients' self-engagement through disease awareness, lifestyle changes, and medication adherence.

METHODS

Prospective, observational, open-label, multi-center, pharmacoepidemiologic study of type 2 diabetes mellitus (T2DM) patients treated de novo with vildagliptin or vildagliptin/metformin. Data were collected at baseline (treatment initiation), 105±15d, and ≥145d.

RESULTS

The evaluable sample included 896 mainly male (58%), overweight (mean±SD BMI=30.3±5.4kg/m²), in later middle age (mean±SD age=64±11years) patients. Over the three visits, mean(±SD) HbA1c levels declined from 8.1%(±1.0) to 7.3%(±1.0) to 7.2%(±0.9); HbA1c control rates rose from 7% to 36% to 43%. Mean±SD FPG levels decreased from 170(±49) to 141(±41) to 139(±42)mg/dL; control rates increased from 12% to 39% to 43% (all p<0.0001). Weight decreased nominally by 2kg (p=0.0290) and BMI by 0.8kg/m² (p<0.0001). Modeling showed patient engagement activities by clinicians and by patients to be major determinants of glycemic outcomes. No unknown safety signals were detected.

CONCLUSIONS

Vildagliptin and vildagliptin/metformin are effective and safe oral agents in the management of T2DM, especially if part of a treatment program with active patient engagement by clinicians and empowered patients.

Trial design and endpoints in clinical transplant research

The number of clinical trials in solid organ transplantation is progressively increasing year on year, but the quality of design and reporting still varies considerably. The constraints on organ availability, improving short-term outcomes, ethics and timescales involved in organ transplantation present unique challenges for trials in this field. An understanding of the methodology and potential pitfalls in clinical research is essential both to interpret trial results and to design robust studies. This review summarizes the scope and quality of reporting in existing transplant clinical trials and details aspects of clinical trial methodology with particular relevance to transplantation. We highlight initiatives designed to improve the quality of this process to ensure that the results of clinical trials are robust, well reported and of use in everyday clinical practice.

A systematic review of health-related quality of life and psychological outcomes after lung transplantation

BACKGROUND

Lung transplantation (LTx) aims to reduce physical disability and mental distress, extend survival, and improve health-related quality of life (HRQoL). In this systematic review we aimed to: (1) augment evidence regarding measures to assess HRQoL and psychological outcomes after LTx; and (2) summarize HRQoL and psychological outcomes after LTx.

METHODS

Validated and standardized instruments with well-known psychometric properties used for assessing HRQoL and psychological outcomes after LTx were identified by means of comprehensive literature searches of PsychINFO and Medline/PubMed, up through March 2014, using the following search terms in various combinations: lung transplantation; physical functioning; symptom experience; mental health; anxiety; depression; distress; social functioning; life satisfaction; and health-related quality of life.

RESULTS

The search strategy identified 371 titles and abstracts. Of these, 279 were retrieved for further assessment and 63 articles selected for final review. Thirty-nine studies were found for HRQoL, 15 for physical functioning, 5 for mental health and 4 for social functioning. A total of 50 psychometric instruments were encountered.

CONCLUSIONS

Considerable heterogeneity exists in methodology, operational concepts and applied outcome measures in the existing literature on HRQoL and psychological outcomes after LTx. Nevertheless, the studies generally point to significant improvements in both mental health and HRQoL post-transplant. Further research is warranted utilizing consistent outcome measures, including LTx-specific measures and longitudinal study designs.

Beneficial effect of belatacept on health-related quality of life and perceived side effects: results from the BENEFIT and BENEFIT-EXT trials

BACKGROUND

Patient-reported outcomes are increasingly incorporated in drug evaluation trials. Whether new immunosuppressive drugs result in an improved health-related quality of life (HRQoL) and a reduced side effect experiences remains unknown. Moreover, the relationship between HRQoL and kidney function has never been investigated in kidney transplant recipients.

METHODS

Using the BENEFIT and BENEFIT-EXT trials, we investigated the following: (a) evolution of HRQoL, assessed by the Medical Outcomes Short Form Health Survey (SF-36) in the first 3 years (baseline, 12, 24, and 36 months) after kidney transplantation; (b) association among kidney function (chronic kidney disease stage), HRQoL, and patient-reported side effects (Modified Transplant Symptom Occurrence and Symptom Distress Scale-59R; BENEFIT trial only); and (c) impact of belatacept and cyclosporine on side effect experience and HRQoL.

RESULTS

In the BENEFIT trial, all subjects reported clinically meaningful improvements compared with baseline and returned to general population scores, both for physical composite score (PCS) and mental composite score Short Form (36) Health Survey at 12 to 36 months after transplantation. In the BENEFIT-EXT trial, this was observed for PCS only. Belatacept-treated patients reported better absolute PCSs compared with cyclosporine-treated patients. The differences were small but statistically significant at all times. Belatacept-treated patients tended to experience less side effects compared with cyclosporine-treated patients, except for dry skin. Worsening kidney function was associated with a significant decrease in HRQoL.

CONCLUSION

Worsening in kidney function was associated with lower HRQoL. Compared with cyclosporine, belatacept was associated with improved HRQoL, suggesting that use of non-nephrotoxic immunosuppressants may affect the patient's side effect experience and improve their HRQoL.

Adherence-related issues in adolescents and young adults with hematological disorders

Nonadherence to medical recommendations is a widespread problem well documented in a multitude of clinical settings. Nonadherence may adversely affect clinical outcomes such as survival and quality of life and increase health-care-related costs. An understanding of the factors driving nonadherence is key to developing effective adherence-enhancing interventions (AEIs). There are ongoing attempts in contemporary adherence research to better define the various components of adherence, to find optimal measures of adherence and correlations with clinical outcomes, and to create a classification system for AEIs. Nonadherence is also widely prevalent among adolescents and young adults (AYAs) with chronic hematological diseases, affecting up to 50% of patients and increasing with age. Combined use of objective (i.e. electronic monitoring, EM) and subjective (i.e. self-report) measures of adherence may be the preferred approach to assess adherence. The unique physical, social and emotional aspects of the AYA life stage are closely related to intricate causes of nonadherence in AYAs such as problems in transition to adult care. Until proven otherwise, the empirical target in AYAs with hematological disorders should be perfect adherence. Multilevel AEIs, EM feedback and behavioral interventions are among the most effective types of AEIs. Despite the magnitude of the problem, only a handful of AEIs have been evaluated among AYAs with hematological disorders. Thus, this is a field with unmet needs warranting high-quality trials using standardized and well-specified assessment methods and interventions. This review discusses the prevalence, definition, causes and clinical implications of nonadherence among AYAs with hematological disorders, along with strategies to measure and improve adherence.

Quality of life in organ transplant recipients participating in an online transplant community

Background

The PatientsLikeMe Organ Transplants online community allows patients to share detailed health information for research.

Objectives

The objectives of our study were to describe and contrast data collected through an online community with the broader organ transplant population.

Methods

Quantitative data were examined with respect to basic demographic characteristics and quantitative data including treatment, symptoms, side effects, and the PatientsLikeMe Quality of Life (PLMQOL) scale. Qualitative data including forum discussion posts and treatment evaluations were examined to support future development of standardized questions that could be added to the platform. Online data were compared with US national registry data from the United Network for Organ Sharing (UNOS).

Results

Within 30 days of account creation, 1,924 single-organ transplant patients provided spontaneous, patient-reported data in the form of 915 reported symptoms, 938 treatment episodes, and 1,215 PLMQOL assessments. Relative to patients in the UNOS registry, online participants were more likely to be female, younger, and white. Lung transplant patients had worse quality-of-life scores than other organs. Average organ transplant quality-of-life scores were most similar to those of HIV patients, faring better than patients with epilepsy, fibromyalgia, mood disorders, Parkinson’s disease, multiple sclerosis, or ALS. Site users generated 2,169 posts to 346 unique topic threads in the transplants forum.

Conclusions

Organ transplant patients are willing to report detailed health data through online communities across key domains—symptoms, treatment effects, and generic quality of life—that constitute the essential core of patient-reported outcomes. Patient-reported outcomes captured online have the potential to accelerate learning about patient experiences but suffer methodological challenges that must be overcome to maximize their utility.

Health-related quality of life after solid organ transplantation: a prospective, multiorgan cohort study

BACKGROUND

Short-term posttransplantation survival and health-related quality of life (HRQoL) is exceptionally high for all patients after organ transplantation; however, predictors of the HRQoL outcome are not well understood. Trajectories of patients' perceived benefit/burden ratio associated with the transplant procedure may differ when taking the organ type for transplantation into account.

METHODS

A prospective, single-center cohort study assessed the trajectories of 354 patients after kidney (n=165), liver (n=53), heart (n=24), and lung (n=112) transplantation at 2, 6, 12, and 24 months with respect to psychosocial outcomes (HRQoL, anxiety, depression, social support, and work performance).

RESULTS

Mean age was 50±13 years, and 61.6% were male in the overall sample. Demographics differed with respect to organ type. HRQoL measured by the mean SF-36 Physical Component Scale was 36.8 (95% confidence interval, 35.7-37.8) and 48.9 (95% confidence interval, 47.2-49.7) for the Psychosocial Component Scale for the entire sample at 2 months and showed a marginal decrease until 24 months after transplantation. Overall, HRQoL increased for all organ types with differing trajectories. Liver patients reported the lowest HRQoL benefit for the majority of the physical (P≤0.01) and psychosocial (P≤0.01) SF-36 subscales. Anxiety (17.4%) and depression (13.8%) were prevalent in the overall sample. Depression symptoms impaired HRQoL outcomes in both SF-36 components and unemployment impacted the SF-36 psychosocial outcomes.

CONCLUSIONS

HRQoL improved after transplantation for all four types of transplant, but the trajectories were different. Regular screening for depression symptoms may diminish psychologic disorders and distress after transplantation and thus may further improve outcomes.

Attitudes to medication after kidney transplantation and their association with medication adherence and graft survival: a 2-year follow-up study

Background. Nonadherence to medication is a common problem after kidney transplantation. The aim of this study was to explore attitudes towards medication, adherence, and the relationship with clinical outcomes. Method. Kidney recipients participated in a Q-methodological study 6 weeks after transplantation. As a measure of medication adherence, respondents completed the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS(©)-interview). Moreover, the intrapatient variability in the pharmacokinetics of tacrolimus was calculated, which measures stability of drug intake. Data on graft survival was retrieved from patient records up to 2 years after transplantation. Results. 113 renal transplant recipients (19-75 years old) participated in the study. Results revealed three attitudes towards medication adherence-attitude 1: "confident and accurate," attitude 2: "concerned and vigilant," and attitude 3: "appearance oriented and assertive." We found association of attitudes with intrapatient variability in pharmacokinetics of tacrolimus, but not with self-reported nonadherence or graft survival. However, self-reported nonadherence immediately after transplantation was associated with lower two-year graft survival. Conclusion. These preliminary findings suggest that nonadherence shortly after kidney transplantation may be a risk factor for lower graft survival in the years to follow. The attitudes to medication were not a risk factor.

Symptom experienced three years after liver transplantation under immunosuppression in adults

Background & Aims

Immunosuppression-related symptom experience has not been covered thoroughly in long-term liver transplant recipients. The aim of this study was to assess the symptom experience of immunosuppressive therapy three years after liver transplantation and to correlate it with adherence to medications and sociodemographic or disease-related characteristics.

Methods

This study included 94 liver transplant recipients who had survived for more than 3 years after liver transplantation. Symptom experience was measured by the 59-Item Modified Transplant Symptom Occurrence and Symptom Distress Scale (MTSOSD-59R) at the outpatient visits. Adherence to immunosuppressive drugs was assessed using the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS).

Results

Itching, concentration or memory problems, and fatigue were the three most frequent or most distressing symptoms. Factors significantly associated with a higher level of symptom frequency and distress were 3- to 5-year time cohort (i.e., time post-transplantation), and younger age. At the item level, concentration or memory problems were the most frequent and distressing symptoms in the 3- to 5-year time cohort. Itching was the most frequent and distressing symptom in the 5- to 9-year time cohort. Finally, relationship was found between symptom experience and nonadherence to immunosuppressive drugs.

Conclusions

Symptoms related to physical complaints or impairments were more often perceived and more distressing for liver transplant recipients 3 years after transplantation. Furthermore, the 3- to 5-year time cohort and younger age were associated with a higher degree of perceived symptom occurrence and symptom distress. Finally, recipients who perceived higher levels of symptom frequency and symptom distress reported higher levels of nonadherence.

The role of goal cognitions, illness perceptions and treatment beliefs in self-reported adherence after kidney transplantation: a cohort study

OBJECTIVE

Nonadherence to immunosuppressive medication (IM) after kidney transplantation is related to poorer patient and graft outcomes; therefore research into modifiable factors associated with nonadherence is a priority. In this prospective cohort study we investigated whether changes in goal cognitions, illness perceptions, and treatment beliefs were related to self-reported medication adherence six months after kidney transplantation.

METHODS

Interviews were conducted with patients in the out-patient clinic six weeks (T1: n=113) and six months (T2: n=106) after transplantation. Self-reported adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS© Interview). The Brief Illness Perceptions Questionnaire, Beliefs about Medicines Questionnaire and questions on goal cognitions were also administered at both time points.

RESULTS

Self-reported nonadherence increased significantly between 6 weeks and 6 months after transplantation from 17% to 27%. Importance of medication adherence as a personal goal and self-efficacy to successfully carry out this goal decreased significantly over time. Perceived necessity of immunosuppressive medication was high but significantly decreased over time. Concerns about the medicines were low. There were no significant changes in illness perceptions or concerns over time. An increase in perceived graft longevity (timeline) was related to higher likelihood of nonadherence six months post-transplant. Furthermore, younger adult patients were more likely to be nonadherent six months after transplantation.

CONCLUSION

The self-reported nonadherence levels found in this study so soon after transplantation demonstrate the need for early and continued intervention after kidney transplantation in order to maximise adherence and consequently clinical outcomes. Changes in (unrealistic) beliefs regarding the longevity of the graft may offer a potential target for intervention among nonadherent patients.

[Anticancer drug adherence]

A large number of anticancer drugs have been introduced during the two last decades with significant impact for survival, making cancer a chronic disease in a growing number of indications. However, these drugs are costly, induce adverse effects and their efficacy frequently depends on the dose. For all these reasons, adherence in cancer therapy is critical for an optimal benefit-risk ratio. Patient adherence remains virtually unexplored in many cancers, such as malignant blood diseases. When measured, adherence is poor, especially when the drug is administered as oral and prolonged therapy (hormonotherapy in breast cancer, imatinib). Physician nonadherence represents another form of drug misadministration; poorly documented, its mechanism remains obscure. Adherence may be measured by a panel of methods, each of them displaying limits and pitfalls, suggesting that several complementary methods should be used in the context of prospective studies. Risk factors are age, socio-educative profile, disease stage and physician profile. This review emphasizes some methods to prevent nonadherence. Finally, this review argues for prospective studies, which should integrate a social pharmacology approach, including medicine, psycho-sociology and economics.

Treatment monitoring program for implementation of adherence to second-line erlotinib for advanced non-small-cell lung cancer

BACKGROUND

Adherence to erlotinib could be a determinant for clinical outcome and treatment toxicity in patients with advanced non-small-cell lung cancer (A-NSCLC).

PATIENTS AND METHODS

In an observational study, the Basel Assessment of Adherence Scale (BAAS), a visual analogue scale (VAS), pill counting, and missed appointment rate were used to evaluate adherence in a first cohort of patients who was prescribed erlotinib without a specifically designed management strategy and in a second cohort of patients followed by an oral treatment monitoring program.

RESULTS

Adherence > 95% by BAAS at 2 months of treatment in the first and second cohorts was 72% and 84%, respectively (P = .042). Adherence by pill counting was 78% and 87% in the first and second cohorts, respectively (P = .0021). Disease control rate (DCR) (complete response [CR] + partial response [PR] + stable disease [SD]) was significantly higher in all patients whose adherence by BAAS at 2 months was ≥ 95% (P = .0266). DCR was higher in the second cohort compared with the first, being 63% (95% confidence interval [CI], 53%-72%) and 44% (95% CI, 30%-58%) in the second and the first cohort, respectively (P = .0368). A significant correlation between the number of adverse events and patient-reported adherence was observed (r = 0.105; P = .0001).

CONCLUSION

Nonadherence may be related to poorer rates of response to erlotinib. Effective interventions to reduce nonadherence need to be implemented.

Validation of the Dutch version of the transplant effects questionnaire in liver transplant recipients

Little is known about the extent to which transplant recipients face emotional problems with the receipt of a transplanted organ. The Transplant Effects Questionnaire (TxEQ) enables the quantification of these problems. This study evaluates the psychometric properties of the Dutch translation of the TxEQ (TxEQ-NL) in a group of liver transplant recipients. Confirmatory factor analyses of the TxEQ-NL revealed an adequate fit with the original version. However, four items showed factor loadings <.40. Internal consistency was acceptable (.66-.79). The small correlations between the TxEQ-NL and generic measures of psychological functioning indicated that the constructs measured are related but distinguishable. Therefore, the TxEQ-NL adds a new dimension to the measurement of psychological functioning of transplant recipients.

Capecitabine to reduce nonmelanoma skin carcinoma burden in solid organ transplant recipients

BACKGROUND

Solidorgan transplant recipients (SOTRs) are at greater risk of nonmelanoma skin cancer (NMSC) than the general population, in large part because of their immunosuppression. Select individual SOTRs demonstrate a rate of tumor development at the upper end of their cohort. Capecitabine, a prodrug converted in the body to 5-fluorouracil (5-FU), may alter the risk for development of NMSC in an individual SOTR with a high rate of tumor development.

OBJECTIVE

To report observations of a series of 10 SOTRs treated with capecitabine as adjuvant prevention for high-incidence NMSC.

METHODS

Ten SOTRs were administered cycles of low-dose oral capecitabine (0.5-1.5 g/m(2) per day) for days 1 to 14 of a 21-day treatment cycle. Measurements (skin screenings, laboratory and toxicity monitoring) were performed every 1 to 3 months. Incidence rates of squamous cell carcinoma (SCC) before and during treatment were determined and compared using the Wilcoxon signed-rank test.

RESULTS

The average incidence rate (mean ± SD) of SCC before treatment (0.56 ± 0.28 SCCs/month, range 0.17-1.17 SCCs/month) declined to 0.16 ± 0.11 SCCs/month (range 0-0.33 SCCs/month) during the first 12 months of treatment (mean reduction 68 ± 30.0%, range 0-100%, p < .005). Reduction in actinic keratosis was observed. Common side effects included fatigue, nausea, hand-and-foot syndrome, gout, and poor renal function. Seven of 10 participants required dose adjustment, and two of these were discontinued from the study drug because of side effects.

LIMITATIONS

Case series design, small observational population.

CONCLUSIONS

SOTRs experienced a clinically and statistically significant decline in incident SCCs during treatment with low-dose oral capecitabine, with varying degrees of side effects. Larger randomized trials will determine the dose and efficacy of capecitabine for adjuvant treatment of NMSC in SOTRs.

Patient adherence to tyrosine kinase inhibitor therapy in chronic myeloid leukemia

Dramatically improved survival associated with tyrosine kinase inhibitor (TKI) therapy has transformed the disease model for chronic myeloid leukemia (CML) to one of long-term management, but treatment success is challenged with poor medication adherence. Many risk factors associated with poor adherence can be ameliorated by close monitoring, dose modification, and supportive care. Controlling risk factors for poor adherence in combination with patient education that includes direct communication between the health care team and the patient are essential components for maximizing the benefits of TKI therapy.

Spinal surgery following organ transplantation

Object

Organ transplantation for renal, liver, cardiac, and pulmonary failure has become more common in recent years, and patients are living longer as a result of improved organ preservation methods, immunosuppressive regimens, and general posttransplant care. Some of these patients undergo spine fusion surgery following organ transplantation, and there is little available information concerning outcomes. The authors report on their experience with and the outcomes of spine fusion in this rare and unique immunosuppressed patient group.

Methods

Using the Current Procedural Terminology and ICD-9 codes for solid organ transplants, bone marrow transplantations (BMTs), and spine fusion surgeries, the authors searched their patient database between 1997 and 2008. Data points of interest included primary diagnosis, type of organ transplant, immunosuppressant drug therapy, complications from spine surgery, and radiographic analysis of spine fusion. Spine fusion was assessed with CT or radiography at the latest follow-up.

Results

The database search results revealed 5999 patients who underwent heart, lung, liver, kidney, pancreas, intestine, or bone marrow transplant between 1997 and 2008. Eighteen of the 5999 patients underwent a spine fusion surgery while receiving immunosuppressive therapy. Organ transplants included kidney, liver, heart, pancreas, and allogenic BMT. There were 3 deaths unrelated to spine fusion within 1 year of the surgery and 1 death immediately after spine surgery. Graft-versus-host disease developed in 1 patient when prednisone was stopped prior to the spine surgery. Thirteen patients underwent follow-up radiographic imaging at an average of 25 months after spine surgery; 12 demonstrated radiographic fusion.

Conclusions

The results suggest that spine fusion rates are adequate despite immunosuppressive therapy in patients undergoing spinal fusion after transplant procedures. The data also illustrate the high morbidity and mortality rates found in the organ transplant patient population.