Mismanaging the gift of life: noncompliance in the context of adult stem cell transplantation

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.

Can pharmacotherapeutic follow-up after allogeneic hematopoietic stem cell transplantation improve medication compliance?

BACKGROUND

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is currently one of the most effective therapies in onco-hematology. For the treatment of the disease and prevention of such complications, a complex pharmacotherapeutic regimen is employed. Non-compliance is prevalent among adolescents and young adults with chronic hematological diseases, being reported by up to 50% of the patients.

OBJECTIVE

To evaluate the results of pharmacotherapeutic follow-up on medication compliance and on the knowledge about pharmacotherapy of patients who underwent allo-HSCT.

METHODS

A single-arm, open-label and non-randomized intervention study developed in an allo-HSCT outpatient clinic. The participants attended pharmaceutical consultations and had their knowledge about pharmacotherapy and medication compliance measured by MedTake and Brief Medication Questionnaire (BMQ), respectively.

RESULTS

A total of 27 patients attended pharmaceutical consultations (4.81 consultations/patient; SD = 1.80). There was an improvement in medication compliance and in knowledge between the first and last consultations (p < 0.05). In the final consultation, 70.37% of the patients showed compliance, with a knowledge rate of 98.35% (SD = 3.63). Non-compliant individuals presented a greater tendency to hospital readmissions. There was no relationship between medication compliance and sociodemographic variables, graft-versus-host disease, and knowledge about pharmacotherapy.

CONCLUSIONS

Pharmacotherapeutic follow-up contributed to improving medication compliance. Knowledge about pharmacotherapy alone does not translate into behaviors, which corroborates the complexity of the biopsychosocial factors associated with medication compliance.

Patient eligibility for hematopoietic stem cell transplantation: a review of patient-associated variables

Assessing patient eligibility for hematopoietic stem cell transplantation (HSCT) remains a complex, multifaceted challenge. Among these challenges, the paucity of comprehensive clinical data to guide decision making remains problematic coupled with unclear trade-offs between patient, disease and local HSCT center factors. Moreover, it is unclear that the modification of poor patient characteristics will improve post-HSCT outcomes. However, the use of Comorbidity Indices and Comprehensive Geriatric Assessments helps meet this challenge, but may be limited by overlapping patient characteristics. The increasing consideration for pre-HSCT psychosocial assessments and interventions remains to be studied. Ultimately, the decision to proceed with a HSCT remains interdisciplinary while considering the available evidence discussed in this review.

Conceptual model and economic experiments to explain nonpersistence and enable mechanism designs fostering behavioral change

BACKGROUND

Medical nonpersistence is a worldwide problem of striking magnitude. Although many fields of studies including epidemiology, sociology, and psychology try to identify determinants for medical nonpersistence, comprehensive research to explain medical nonpersistence from an economics perspective is rather scarce.

OBJECTIVES

The aim of the study was to develop a conceptual framework that augments standard economic choice theory with psychological concepts of behavioral economics to understand how patients' preferences for discontinuing with therapy arise over the course of the medical treatment. The availability of such a framework allows the targeted design of mechanisms for intervention strategies.

METHODS

Our conceptual framework models the patient as an active economic agent who evaluates the benefits and costs for continuing with therapy. We argue that a combination of loss aversion and mental accounting operations explains why patients discontinue with therapy at a specific point in time. We designed a randomized laboratory economic experiment with a student subject pool to investigate the behavioral predictions.

RESULTS

Subjects continue with therapy as long as experienced utility losses have to be compensated. As soon as previous losses are evened out, subjects perceive the marginal benefit of persistence lower than in the beginning of the treatment. Consequently, subjects start to discontinue with therapy.

CONCLUSIONS

Our results highlight that concepts of behavioral economics capture the dynamic structure of medical nonpersistence better than does standard economic choice theory. We recommend that behavioral economics should be a mandatory part of the development of possible intervention strategies aimed at improving patients' compliance and persistence behavior.

The impact of smoking on outcomes among patients undergoing hematopoietic SCT for the treatment of acute leukemia

A paucity of research exists examining the potential impact of tobacco use on cancer treatment outcomes, especially among patients treated with hematopoietic stem cell transplantation (HSCT). A retrospective cohort study design was utilized to examine the impact of smoking on duration of hospitalization and overall survival among 148 consecutive patients undergoing HSCT for treatment of acute leukemia from 1999 to 2005. Of the 148 patients, 15% reported current smoking, 30% former smoking, and 55% never used tobacco. Patients were followed for a median 3.5 years (Interquartile Range= 2.1-5.5). Compared to no history of smoking, current smoking was associated with worse pre-HSCT pulmonary function tests (p< .02 in each case), more days hospitalized (46.2 versus 25.7 days, p = 0.025, and poorer overall survival (HR=1.88; 95% CI 1.09-3.25). Results were similar after multivariate adjustment, although the association with overall survival attenuated slightly (HR=1.75, 95% CI 1.00-3.06). Current smoking appears to adversely affect the number of days hospitalized post-HSCT and overall survival. Translational research focused on interventions to promote tobacco cessation may lead to improved HSCT outcomes.

Coping with illness and subjective theories of illness in adult patients with haematological malignancies: systematic review

In parallel to development of individualised antineoplastic treatment, scientific interest in patients' subjective theories of illness (STOI) has emerged in the oncological community. STOI depend decisively on patients' information about their disease. Coping with illness is dependent from the individual situation and context, and it is generally modulated by patients' STOI. The purpose is fivefold: (1) to provide a thorough literature review about coping and about STOI in adult haematological patients, (2) to survey through which indicators the topics were operationalized in studies, (3) to clarify the kind of coherence between these two topics, (4) to explicate the interaction between STOI and other variables, and (5) to verify the clinical relevance of both topics. We searched 19 electronic databanks for English biomedical literature manuscripts (1995-2008) on this subject. Twenty-six studies met our criteria and varied in haematological entity, treatment concept, sample size and methodological design. We conclude that a subjective-individual regulation of patient's mental stability during a cytotoxic chemotherapy is important. Successful coping strategies develop not only based on objective, but also subjective evaluation mechanisms. We deduce consequences for doctor-patient communication and psychosocial care in haematology. The newly developed process model of subjective regulation in cancer patients, in general, views the oncological treatment process as a procedural mental evaluation.

Allogeneic BMT and patient eligibility based on psychosocial criteria: a survey of BMT professionals

BMT professionals were compared regarding their willingness to proceed with allogeneic BMT given select psychosocial issues. A questionnaire was sent to 660 physician members of ASBMT, 92 social work members of BMT Special Interest Group, Association of Oncology Social Work, and 626 nurse members of BMT Special Interest Group, Oncology Nursing Society; 597 responded with a response rate of 43.5%. Items included background information, followed by 17 case vignettes; each represented a different psychosocial issue to which respondents indicated whether or not they would recommend proceeding with allogeneic BMT. In every vignette, at least 10% of respondents indicated they would not proceed. In six vignettes, at least 64% indicated do not proceed: suicidal ideation (86.8%), uses addictive illicit drugs (81.7%), history of noncompliance (80.5%), no lay caregiver (69.3%), alcoholic (64.8%), and mild dementia/Alzheimer's (64.4%). In 10 vignettes, at least 73% indicated proceed. On four vignettes, professional subgroups differed in their recommendation on whether or not to proceed with allogeneic BMT. Qualitative data suggest that this decision is contingent on the perceived acuity, severity, and currency of the psychosocial issue, patient ability to comply with treatment given the issue, and its manageability as a risk factor for treatment related vulnerability and outcomes.