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Kengne AP, Brière JB, Gudiña IA, Jiang X, Kodjamanova P, Bennetts L, Khan ZM. The impact of non-pharmacological interventions on adherence to medication and persistence in dyslipidaemia and hypertension: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2024:1-10. [PMID: 38366854 DOI: 10.1080/14737167.2024.2319598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/13/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Suboptimal medication adherence is common among patients with cardiovascular diseases. We sought evidence on non-pharmacological interventions used to support adherence for patients with hypertension and/or dyslipidemia. METHODS We searched MEDLINE, EMBASE, MEDLINE In-Process, ClinicalTrials.gov, EUCTR, and conference proceedings from July 2011 to July 2021 to identify trials evaluating effects of health education, phone reminders, or digital interventions on medication adherence or persistence of adult patients with hypertension and/or dyslipidemia. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool v2. RESULTS Of 64 studies, 62 used health education approaches (e.g. educational interviews, motivational meetings, advice from physicians, and mobile health content), 16 phone reminders (e.g. text reminders, electronic pill-box linked reminders, bi-directional text messaging), and 10 digital applications as interventions (e.g., various self-management applications). All studies assessed medication adherence; only two persistence. Overall, 30 studies (83%) assessing health education approaches alone and 25 (78%) combined with other strategies, 12 (75%) phone reminders and eight studies (80%) digital applications combined with other strategies reported improved medication adherence. Two studies assessing health education approaches reported improved persistence. CONCLUSIONS Our findings indicate non-pharmacological interventions may positively impact adherence. Therefore, 'beyond the pill' approaches could play a role in preventing cardiovascular diseases.
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Affiliation(s)
| | | | | | - Xiaobin Jiang
- Health Economics and Market Access, Amaris Consulting, Shanghai, China
| | - Petya Kodjamanova
- Health Economics and Market Access, Amaris Consulting, Sofia, Bulgaria
| | - Liga Bennetts
- Health Economics and Market Access, Amaris Consulting, Montréal, Canada
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Varnell CD, Rich KL, Modi AC, Hooper DK, Eckman MH. A Cost-effectiveness Analysis of Adherence Promotion Strategies to Improve Rejection Rates in Adolescent Kidney Transplant Recipients. Am J Kidney Dis 2022; 80:330-340. [PMID: 35227823 PMCID: PMC9398956 DOI: 10.1053/j.ajkd.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/16/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Nonadherence to medical regimens increases the risk of graft loss among adolescent and young adult recipients of kidney transplants. Interventions that improve adherence may decrease rejection rates, but their perceived costs are a barrier to clinical implementation. We developed a model to assess the cost-effectiveness of an adherence promotion strategy, the Medication Adherence Promotion System (MAPS). STUDY DESIGN Simulation-based. Data sources included published articles indexed in Medline or referenced in bibliographies of relevant English-language articles. Data on costs and outcomes were taken from a single clinical center. SETTING & POPULATION US adolescent patients after their first kidney transplant. INTERVENTION Usual posttransplant care versus usual care plus MAPS. OUTCOME Effectiveness measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars. MODEL, PERSPECTIVE, & TIMEFRAME Markov state transition decision model. We used a health care system perspective with a lifelong time horizon. RESULTS In the base-case analysis, MAPS was more effective and less costly than usual care. MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Extending results to a program level with 100 patients, any adherence promotion intervention similar in effectiveness to MAPS would cost less than $50,000/QALY if the start-up costs were <$2.5 million and annual costs <$188,000. Strategies with costs similar to MAPS that reduce the risk of rejection by as little as 3% would also have similar cost-effectiveness. LIMITATIONS Estimates of components and costs for MAPS were based on a single center. CONCLUSIONS Adherence promotion strategies with costs similar to MAPS can be cost-effective as long as they reduce rejection rates by at least 3%. This model can be applied to study the cost-effectiveness of adherence promotion strategies with varying costs and outcomes.
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Affiliation(s)
- Charles D Varnell
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Kristin L Rich
- Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Avani C Modi
- Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - David K Hooper
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.
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Gaynor JJ, Guerra G, Roth D, Chen L, Kupin W, Mattiazzi A, Ortigosa-Goggins M, Tabbara MM, Moni L, Burke GW 3rd, Ciancio G. Graft Failure Due to Nonadherence among 150 Prospectively-Followed Kidney Transplant Recipients at 18 Years Post-transplant: Our Results and Review of the Literature. J Clin Med 2022; 11. [PMID: 35268424 DOI: 10.3390/jcm11051334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/15/2023] Open
Abstract
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.
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Hooper DK, Varnell CD, Rich K, Carle A, Huber J, Mostajabi F, Dahale D, Pai ALH, Goebel J, Modi AC. A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study. Am J Kidney Dis 2021; 79:335-346. [PMID: 34352285 DOI: 10.1053/j.ajkd.2021.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Adolescent and young adult kidney transplant recipients have high risk of rejection related to suboptimal adherence. Multi-component interventions improve adherence in controlled trials, but clinical implementation is lacking. We describe an initiative to reduce allograft rejection using evidence-based adherence promotion clinical strategies. STUDY DESIGN Interrupted time series. SETTING AND PARTICIPANTS Kidney transplant recipients cared for at Cincinnati Children's Hospital ≥1 year post-transplant and taking ≥1 immunosuppressive medication from 2014 through 2017. QUALITY IMPROVEMENT ACTIVITIES The following interventions were implemented over 14 months: 1) adherence promotion training for clinical staff, 2) EHR-supported adherence risk screening, 3) systematic assessment of medication adherence barriers, 4) designation of specific staff to address adherence barriers, 5) shared decision-making with the patients to overcome adherence barriers, 6) follow-up to assess progress, 7) optional electronic medication monitoring. OUTCOMES Primary Outcome: Late acute rejection. Process measures: barriers assessments performed, barriers identified, number of interventions performed. Secondary outcomes/balancing measures: de novo DSA, biopsy rate, rejections per biopsy. ANALYTICAL APPROACH Time series analysis using statistical process control, evaluated patient-days between acute rejections as well as monthly rejections per 100 patient-months before and after implementation. To control for known rejection risk factors including changes in treatment and case mix, multivariable analyses were performed. RESULTS The monthly rejection rate fell from 1.61 rejections/100 patient-months in the 26-months pre-implementation to 0.88 rejections/100 patient-months in the 22-months post-implementation. In multivariable analysis, MAPS was associated with a 50% reduction in rejection incidence (IRR 0.50, 95% CI: 0.27-0.91, p=0.02). DSA and time since transplant were also associated with rejection incidence (IRR 2.27, p=0.02 and IRR 0.87, p=0.02, respectively) LIMITATIONS: A single center study. Potential confounding by unmeasured variables. CONCLUSIONS Clinical implementation of evidence-based adherence-promotion strategies was associated with a 50% reduction in acute rejection incidence over two years.
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Affiliation(s)
- David K Hooper
- Division of Nephrology (MLC-7022), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229.
| | - Charles D Varnell
- Division of Nephrology (MLC-7022), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Kristin Rich
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Adam Carle
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; Univerisity of Cincinnati, Collage of Arts and Sciences, Department of Psychology, 155 B McMicken Hall Cincinnati, OH 45221
| | - John Huber
- Department of Information Services (MLC 9009), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Farida Mostajabi
- James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Devesh Dahale
- Southeast Alabama Medical Center, 1108 Ross Clark Circle, Dothan, AL 36301
| | - Ahna L H Pai
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Jens Goebel
- Section of Pediatric Nephrology, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503; Department of Pediatrics and Human Development, Michigan State University, Life Sciences Bldg. 1355 Bogue St., B240, East Lansing MI 48824
| | - Avani C Modi
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
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Masimula QK, van der Wath A, Coetzee I. Promoting a person-centred workplace culture in a public nursing education institution in South Africa by fostering effective teamwork amongst nurse educators. Nurse Educ Today 2021; 99:104783. [PMID: 33548572 DOI: 10.1016/j.nedt.2021.104783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Promoting a person-centred workplace culture in organisations is one of the most challenging tasks for both employers and employees. Person-centred workplace cultures and effective teamwork have been linked to achieving optimal organisational outcomes. AIM We report nurse educators' perceptions of the elements required for effective teamwork to promote a person-centred workplace culture in a public nursing education institution in South Africa. METHODS A consensus meeting with 32 participants, purposively selected from a population of nurse educators and nursing managers. Data were collected during the consensus meeting, which was facilitated by two external nursing education experts. Data were analysed thematically. RESULTS Three main themes emerged during the consensus meeting in relation to effective teamwork. The first theme was positive work relations, with categories of: knowing self and others, respecting self and others and trusting self and others. The second theme that emerged was effective communication with categories of: sharing information, cultural sensitivity and diversity. The third theme was group cohesion with categories of: active participation, adherence to work plan, collective vision of goals and collective decision making. CONCLUSION Positive work relations open the door towards effective teamwork. Effective communication ensures the smooth dissemination of information and feedback to facilitate effective teamwork and in turn promote a person-centred workplace culture.
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Affiliation(s)
| | | | - Isabel Coetzee
- Department of Nursing Science, University of Pretoria, Pretoria, South Africa.
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