Psychosocial Assessment of Candidates for Transplantation scale (PACT) and survival after allogeneic hematopoietic stem cell transplantation

Disparities in access to hematopoietic cell transplant persist at a transplant center

Disparities in access to hematopoietic cell transplant (HCT) are well established. Prior studies have identified barriers, such as referral and travel to an HCT center, that occur before consultation. Whether differences in access persist after evaluation at an HCT center remains unknown. The psychosocial assessment for transplant eligibility may impede access to transplant after evaluation. We performed a single-center retrospective review of 1102 patients who underwent HCT consultation. We examined the association between race/ethnicity (defined as Hispanic, non-Hispanic Black, non-Hispanic White, and Other) and socioeconomic status (defined by zip code median household income quartiles and insurance type) with receipt of HCT and Psychosocial Assessment of Candidates for Transplantation (PACT) scores. Race/ethnicity was associated with receipt of HCT (p = 0.02) with non-Hispanic Whites comprising a higher percentage of HCT recipients than non-recipients. Those living in higher income quartiles and non-publicly insured were more likely to receive HCT (p = 0.02 and p < 0.001, respectively). PACT scores were strongly associated with income quartiles (p < 0.001) but not race/ethnicity or insurance type. Race/ethnicity and socioeconomic status impact receipt of HCT among patients evaluated at an HCT center. Further investigation as to whether the psychosocial eligibility evaluation limits access to HCT in vulnerable populations is warranted.

[Allogeneic hematopoietic stem cell transplantation and treatment with CAR-T cells - identification of psycho-social vulnerability factors: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

Allogeneic hematopoietic stem cell transplantation (HCT) and CAR-T cells therapy are treatments with curative aim for certain hematological malignancies, refractory or relapse. Nevertheless, they carry the risk of morbidity and mortality and may have a significant psychosocial impact, particularly for HCT. It is therefore necessary to identify psychological difficulties and social problems, as well as the patient's resources, and those of his entourage, in order to improve his overall management. The objective of this evaluation is not to pose contraindications to treatments, but to adapt the personalized care project. This identification must be carried out early on in the pre-HCT assessment journey to enable the implementation of appropriate actions by the various care providers. Based on a review of the literature, we designed a psychosocial data collection grid that can be initiated in pre-transplant and updated by accompanying the patient at each stage of follow-up (discharge from hospital, day-hospital follow-up, D100 evaluation). This grid is divided into 3 axes: socio-family context, psychological and somatic aspects. This tool allows the traceability of the interventions of different professionals and is a support for multidisciplinary exchanges.

Compliance with medical regimen among hematological cancer patients and its association with symptoms of posttraumatic stress disorder and adjustment disorder

Background

Hematological cancer patients must comply with extensive medical instructions to prevent cancer progression or relapse. Psychological comorbidities and patient characteristics have been shown to affect compliance. However, the impact of posttraumatic stress disorder (PTSD) and adjustment disorder (AjD) on compliance in cancer patients remains unclear. This study aims to evaluate compliance in hematological cancer patients more comprehensively and to investigate its association with PTSD and AjD symptomatology as well as sociodemographic and medical factors.

Methods

Hematological cancer patients were cross-sectionally assessed via validated questionnaires for PTSD (PCL-5) and AjD (ADMN-20), and three internally developed items on compliance with medical regimen, with two referring to compliance behavior and one item assessing perceived difficulties with complying. Each compliance item was analyzed descriptively. Multiple linear regression models tested the association between compliance and PTSD and AjD symptomatology, sociodemographic and medical factors.

Results

In total, 291 patients were included (response rate 58%). Nine out of ten patients reported to either never (67%) or rarely (25%) change their medical regimen. However, 8% reported to change it once in a while or often. Compliance behavior was mostly rated as very easy (36%) or easy (45%) to implement. Nevertheless, 19% perceived it to be partly difficult or difficult to follow medical regimen. Symptoms of AjD (β = 0.31, p < 0.001) were associated with more difficulties to comply. Higher compliance behavior in turn was associated with stem cell transplantation (SCT) treatment (β = -0.21, p < 0.001) and lower education (β = -0.19, p = 0.002).

Conclusion

Although most patients indicated that they comply with medical regimen, a considerable subgroup of patients indicated subjectively perceived difficulties and thus seem to require additional support in implementing medical instructions possibly through improved medical communication and patient health literacy or shared decision-making.

Characterization of the stanford integrated psychosocial assessment for transplant for heart, liver, and kidney transplant candidates in Japan

BACKGROUND

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive psychosocial assessment proven useful for predicting the outcomes of organ transplantation that is expected to be useful in Japan. However, the characteristics of organ-specific SIPAT scores for organ transplant recipient candidates in Japan are unclear and, to date, the SIPAT has not been properly utilized in clinical practice. The purpose of this study was to present basic data that can be used to establish the relation between SIPAT scores and post-transplantation psychosocial outcomes as well as organ-specific outcomes.

METHODS

This study included 167 transplant recipient candidates (25 heart, 71 liver, and 71 kidney) who completed a semi-structured interview based on the Japanese version of SIPAT (SIPAT-J) prior to transplantation. The differences between organs in terms of SIPAT scores and differences in SIPAT scores based on demographic data were comparatively analyzed.

RESULTS

The total SIPAT scores were higher for liver recipient candidates than for heart recipient candidates (P = .019). Regarding the subscales, SIPAT B (social support system) scores were higher for liver and kidney recipient candidates than for heart recipient candidates (P = .021), whereas SIPAT C (psychological stability and psychopathology) scores were higher for liver recipient candidates than for kidney recipient candidates (P = .002). Recipient candidates with a history of psychiatric treatment and those who were unemployed had higher SIPAT scores, regardless of the transplant organ, than recipient candidates without a history of psychiatric treatment and those who were employed (P < .001, P = .016, respectively).

CONCLUSIONS

There were notable differences in the total SIPAT-J and subscale scores among the liver, heart, and kidney recipient candidates. Each organ was associated with specific psychosocial issues that should be addressed before transplantation. Interventions such as information provision and patient education based on SIPAT assessment results for each organ may improve recipient post-transplant outcomes.

Medication Adherence among Allogeneic Haematopoietic Stem Cell Transplant Recipients: A Systematic Review

Recipients of a haematopoietic stem cell transplantation (HSCT) may experience issues in medication adherence (MA) when discharged. The primary aim of this review was to describe the oral MA prevalence and the tools used to evaluate it among these patients; the secondary aims were to summarise factors affecting medication non-adherence (MNA), interventions promoting MA, and outcomes of MNA. A systematic review (PROSPERO no. CRD42022315298) was performed by searching the Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane Library, Excerpta Medica dataBASE (EMBASE), PsycINFO, PubMed and Scopus databases, and grey literature up to May 2022 by including (a) adult recipients of allogeneic HSCT, taking oral medications up to 4 years after HSCT; (b) primary studies published in any year and written in any language; (c) with an experimental, quasi-experimental, observational, correlational, and cross-sectional design; and (d) with a low risk of bias. We provide a qualitative narrative synthesis of the extracted data. We included 14 studies with 1049 patients. The median prevalence of MA was 61.8% and it has not decreased over time (immunosuppressors 61.5% [range 31.3-88.8%] and non-immunosuppressors 65.2% [range 48-100%]). Subjective measures of MA have been used most frequently (78.6%) to date. Factors affecting MNA are younger age, higher psychosocial risk, distress, daily immunosuppressors, decreased concomitant therapies, and experiencing more side effects. Four studies reported findings about interventions, all led by pharmacists, with positive effects on MA. Two studies showed an association between MNA and chronic graft-versus-host disease. The variability in adherence rates suggests that the issues are relevant and should be carefully considered in daily practice. MNA has a multifactorial nature and thus requires multidisciplinary care models.

A conceptual framework of the psychosocial elements that should be assessed in candidates for hematopoietic cell transplant: Social workers' and psychologists' perspectives

Background: The aim of this work was to explicate a conceptual framework of psychosocial elements assessed in candidates for hematopoietic cell transplant (HCT) and to explore differences in the conceptualization based on the use of risk rating scales in clinical practice.Methods: Concept mapping is a mixed methods participatory approach to elicit and organize the ideas of a group of stakeholders and produce a composite conceptual framework. Participants were social workers and psychologists with experience assessing HCT candidates.Results: Participants brainstormed 114 psychosocial elements and conceptualized them into 12 distinct clusters: Transplant Mindset, Support System, Caregiver, Lodging and Transportation, Financial and Legal, Work, Demographic Characteristics, Mental Health, Communication, Educational and Resource Needs, Physical Functioning, and Cognition. Participants who used risk rating scales did not prioritize the importance of the clusters differently than those who did not.Conclusions: The conceptualization converges and diverges with the literature. Divergences are of particular interest since the perspectives of practicing psychosocial professionals have been largely absent from the literature. The conceptual framework can guide psychosocial providers in assessing patients. Assessing the caregiver is a high priority, as is evaluating the patient's mental health and mindset about transplant.

Psychosocial Assessment of Candidates for Hematopoietic Cell Transplantation: A National Survey of Centers' Practices

OBJECTIVE

This study characterizes pre-hematopoietic cell transplant psychosocial assessment practices with adult patients at centers in the U.S. An online, cross-sectional survey was conducted to describe the content and process of assessment including the high risk factors that influence transplant eligibility and how eligibility decisions are made.

METHODS

Psychosocial professionals (one per center) were invited to participate by sharing their center's practice. The questionnaire was developed by the researchers and pre-tested with a group of HCT social workers. Univariate statistics were used to describe the sample as well as the content and process of psychosocial assessment. Content analysis was conducted on textual data.

RESULTS

A total of 90 centers had one psychosocial professional that responded. There was general consistency among centers about the major psychosocial components that are assessed, but variation occurred regarding what, if any, standardized measures were used. Approximately half of centers that used standardized measures used the PACT, TERS, or SIPAT to rate overall psychosocial risk. Most respondents (86%) reported that their center has declined an otherwise medically eligible patient due to psychosocial risk factors. Risk factors most frequently reported as potentially influencing eligibility included no caregiver/poor support system, illicit drug use, and serious, untreated mental illness.

CONCLUSIONS

Study findings provide a fuller understanding of psychosocial assessment practices, including the challenging ethical issue of psychosocial eligibility, and will help inform best practices. This article is protected by copyright. All rights reserved.

Increasing access to allotransplants in the United States: the impact of race, geography, and socioeconomics

Allogeneic hematopoietic cell transplantation (HCT) is particularly susceptible to racial, socioeconomic, and geographic disparities in access and outcomes given its specialized nature and its availability in select centers in the United States. Nearly all patients who need HCT have a potential donor in the current era, but racial minority populations are less likely to have an optimal donor and often rely on alternative donor sources. Furthermore, prevalent health care disparity factors are further accentuated and can be barriers to access and referral to a transplant center. Research has primarily focused on defining and quantifying a variety of social determinants of health and their association with access to allogeneic HCT, with a focus on race/ethnicity and socioeconomic status. However, research on interventions is lacking and is an urgent unmet need. We discuss the role of racial, socioeconomic, and geographic disparities in access to allogeneic HCT, along with policy changes to address and mitigate them and opportunities for future research.

Psychosocial Assessment of Transplant Candidates: Inter-rater Reliability and Concurrent Validity of the Japanese Version of the Stanford Integrated Psychosocial Assessment for Transplantation

BACKGROUND

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive instrument developed to provide a standardized, objective, and evidence-based psychosocial evaluation of the main pretransplant psychosocial risk factors that may influence transplant outcomes.

OBJECTIVE

Because established assessment procedures or standardized tools designed to perform pre-solid organ transplant psychosocial evaluation are currently unavailable in Japan, the present study aimed to develop and preliminarily validate the Japanese version of the SIPAT.

METHODS

First, the Japanese version of the SIPAT was developed using standard forward-back-translation procedures. Then, the Japanese versions of the SIPAT and the Japanese version of Psychosocial Assessment of Candidates for Transplant were retrospectively and blindly applied to 107 transplant cases by 4 independent raters.

RESULTS

The interrater reliability of the scores obtained with the Japanese version of the SIPAT was excellent (Pearson's correlation coefficient = 0.86). The concurrent validity of the SIPAT to the Psychosocial Assessment of Candidates for Transplant for each examiner was substantial (Spearman's rank correlation coefficient = -0.66).

CONCLUSION

These findings suggest that the Japanese version of the SIPAT is a promising and reliable instrument. Further research is required to test the predictive validity of the Japanese version of the SIPAT.

It Takes a Team to Make It Through: The Role of Social Support for Survival and Self-Care After Allogeneic Hematopoietic Stem Cell Transplant

Background

Social support plays an important role for health outcomes. Support for those living with chronic conditions may be particularly important for their health, and even for their survival. The role of support for the survival of cancer patients after receiving an allogeneic hematopoietic cell transplant (alloHCT) is understudied. To better understand the link between survival and support, as well as different sources and functions of support, we conducted two studies in alloHCT patients. First, we examined whether social support is related to survival (Study 1). Second, we examined who provides which support and which specific support-related functions and tasks are fulfilled by lay caregivers and healthcare professionals (Study 2).

Methods

In Study 1, we conducted a retrospective chart review of alloHCT patients (N = 173, 42.8% female, age: M = 49.88) and registered availability of a dedicated lay caregiver and survival. In Study 2, we prospectively followed patients after alloHCT (N = 28, 46.4% female, age: M = 53.97, 46.4% ethnic minority) from the same hospital, partly overlapping from Study 1, who shared their experiences of support from lay caregivers and healthcare providers in semi-structured in-depth interviews 3 to 6 months after their first hospital discharge.

Results

Patients with a dedicated caregiver had a higher probability of surviving to 100 days (86.7%) than patients without a caregiver (69.6%), OR = 2.84, p = 0.042. Study 2 demonstrated the importance of post-transplant support due to patients’ emotional needs and complex self-care regimen. The role of lay caregivers extended to many areas of patients’ daily lives, including support for attending doctor’s appointments, managing medications and financial tasks, physical distancing, and maintaining strict dietary requirements. Healthcare providers mainly fulfilled medical needs and provided informational support, while lay caregivers were the main source of emotional and practical support.

Conclusion

The findings highlight the importance of studying support from lay caregivers as well as healthcare providers, to better understand how they work together to support patients’ adherence to recommended self-care and survival.

Psychosocial Pre-Transplant Screening With the Transplant Evaluation Rating Scale Contributes to Prediction of Survival After Hematopoietic Stem Cell Transplantation

There is no standard in hematopoietic stem cell transplantations (HSCT) for pre-transplant screening of psychosocial risk factors, e.g., regarding immunosuppressant non-adherence. The aim of this prospective study is to explore the predictive value of the pretransplant psychosocial screening instrument Transplant Evaluation Rating Scale (TERS) for mortality in a 3-year follow-up. Between 2012 and 2017 61 patients were included and classified as low (TERS = 26.5-29) and increased-risk group (TERS = 29.5-79.5). Both groups were compared regarding mortality until 36 months after transplantation and secondary outcomes [Medication Experience Scale for Immunosuppressants (MESI); incidence/grade of GvHD]. The increased-risk group (n = 28) showed significantly worse cumulative survival in the outpatient setting (from 3 months to 3 years after HSCT) [Log Rank (Mantel Cox) P = 0.029] compared to low-risk group (n = 29) but there was no significant result for the interval immediately after HSCT until 3 years afterwards. Pre-transplant screening with TERS contributes to prediction of survival after HSCT. The reason remains unclear, since TERS did not correlate with GvHD or MESI. The negative result regarding the interval immediately after HSCT until 3 years could be caused by the intensive in-patient setting with mortality which is explained rather by biological reasons than by non-adherence.

Clinicians and patients perspectives on follow-up care and eHealth support after allogeneic hematopoietic stem cell transplantation: A mixed-methods contextual analysis as part of the SMILe study

PURPOSE

We report on our contextual analysis's methodology, as a first step of an implementation science project aiming to develop, implement, and test the effectiveness of an integrated model of care in SteM-cell transplantatIon faciLitated by eHealth (SMILe).

METHODS

We applied an explanatory sequential mixed-methods design including clinicians and patients of the University Hospital Freiburg, Germany. Data were collected from 3/2017 to 1/2018 via surveys in 5 clinicians and 60 adult allogeneic stem-cell transplantation patients. Subsequently, we conducted 3 clinician focus groups and 10 patient interviews. Data analysis followed a 3-step process: (1) creating narrative descriptions, tables, and maps; (2) mapping key observational findings per dimension of the eHealth-enhanced Chronic-Care Model; (3) reflecting on how findings affect our choice of implementation strategies.

RESULTS

Current clinical practice is mostly acute care driven, with no interdisciplinarity and weak chronic illness management. Gaps were apparent in the dimensions of self-management support and delivery-system design. Health behaviors that would profit from support include medication adherence, physical activity and infection prevention. The theme "being alone and becoming an expert" underpinned patients need to increase support in hospital-to-home transitions. Patients reported insecurity about recognizing, judging and acting upon symptoms. The theme "eHealth as connection not replacement" underscores the importance of eHealth augmenting, not supplanting human contact. Synthesis of our key observational findings informed eight implementation strategies.

CONCLUSION

Stakeholders are willing towards a chronic care-focused approach and open for eHealth support. The contextual information provides a basis for the SMILe model's development and implementation.