Can Focusing on Self-Care Reduce Disparities in Kidney Transplantation Outcomes?

MyKidneyCoach, Patient Activation, and Clinical Outcomes in Diverse Kidney Transplant Recipients: A Randomized Control Pilot Trial

Kidney transplant (KT) recipients who are not actively engaged in their care and lack self-management skills have poor transplant outcomes, which are disproportionately observed among Black KT recipients. This pilot study aimed to determine whether the MyKidneyCoach app, an mHealth intervention that provides self-management monitoring and coaching, improved patient activation, engagement, and nutritional behaviors in a diverse KT population.

Methods

This was a randomized, age-stratified, parallel-group, attention-control, pilot study in post-KT patients. Participants were randomized into the attention-control with access to MyKidneyCoach for education and self-management (n = 9) or the intervention with additional tailored nurse coaching (n = 7). Feasibility, acceptability, and clinical outcomes were assessed.

Results

The acceptability of MyKidneyCoach by System Usability Scale was 67.5 (95% confidence interval [CI], 59.1-75.9). Completion rates based on actively using MyKidneyCoach were 81% (95% CI, 57%-93%) and study retention rate of 73%. Patient activation measure significantly increased overall by a mean of 11 points (95% CI, 3.2-18.8). Additionally, Black patients (n = 7) had higher nutrition self-efficacy scores of 80.5 (95% CI, 74.4-86.7) compared with 75.6 (95% CI, 71.1-80.1) in non-Black patients (n = 9) but lower patient activation measure scores of 69.3 (95% CI, 56.3-82.3) compared with 71.8 (95% CI, 62.5-81) in non-Black patients after 3 mo.

Conclusions

MyKidneyCoach was easy to use and readily accepted with low attrition, and improvements were demonstrated in patient-reported outcomes. Both Black and non-Black participants using MyKidneyCoach showed improvement in self-management competencies; thus, this intervention may help reduce healthcare inequities in KT.

Living Well With Kidney Disease and Effective Symptom Management: Consensus Conference Proceedings

Chronic kidney disease (CKD) confers a high burden of uremic symptoms that may be underrecognized, underdiagnosed, and undertreated. Unpleasant symptoms, such as CKD-associated pruritus and emotional/psychological distress, often occur within symptom clusters, and treating 1 symptom may potentially alleviate other symptoms in that cluster. The Living Well with Kidney Disease and Effective Symptom Management Consensus Conference convened health experts and leaders of kidney advocacy groups and kidney networks worldwide to discuss the effects of unpleasant symptoms related to CKD on the health and well-being of those affected, and to consider strategies for optimal symptom management. Optimizing symptom management is a cornerstone of conservative and preservative management which aim to prevent or delay dialysis initiation. In persons with kidney dysfunction requiring dialysis (KDRD), incremental transition to dialysis and home dialysis modalities offer personalized approaches. KDRD is proposed as the preferred term given the negative connotations of "failure" as a kidney descriptor, and the success stories in CKD journeys. Engaging persons with CKD to identify and prioritize their personal values and individual needs must be central to ensure their active participation in CKD management, including KDRD. Person-centered communication and care are required to ensure diversity, equity, and inclusion; education/awareness that considers the health literacy of persons with CKD; and shared decision-making among the person with CKD, care partners, and providers. By putting the needs of people with CKD, including effective symptom management, at the center of their treatment, CKD can be optimally treated in a way that aligns with their goals.

A qualitative exploration of the facilitators and barriers to self-management in kidney transplant recipients

Background

Understanding the behaviours that facilitate or impede one’s ability to self-manage is important to improve health-related outcomes in kidney transplant recipients (KTRs). Previous studies exploring the self-management experiences of KTRs have focused on specific tasks (e.g., medication adherence), age groups (e.g., adolescent or older recipients), or have been conducted outside of the UK where transferability of findings is unknown. Our study aimed to explore the perceptions and experiences of self-management in UK KTRs to identify facilitators and barriers associated with self-management tasks.

Methods

Semi-structured interviews were conducted with eleven KTRs. Topics explored included experiences of self-management tasks (diet, exercise, medications, stress management), perceived healthcare role, and future interventional approaches. Thematic analysis was used to identify and report themes.

Results

Eight themes were identified which were mapped onto the three self-management tasks described by Corbin and Strauss: medical, role and emotional management. Perceived facilitators to self-management were: gathering health-related knowledge, building relationships with healthcare professionals, creating routines within daily life, setting goals and identifying motivators, establishing support networks, and support from family and friends. Complexity of required treatment and adjusting to a new health status were perceived barriers to self-management.

Conclusions

Participants described the importance of collaborative consultations and continuity of care. Tailored interventions should identify individualised goals and motivators for participating in self-management. Education on effective strategies to manage symptoms and comorbidities could help alleviate KTRs’ perceived treatment burden. Family and peer support could emotionally support KTRs; however, managing the emotional burden of transplantation warrants more attention.

Graphic abstract

Effectiveness of IT-based interventions on self-management in adult kidney transplant recipients: a systematic review

Background

Kidney transplant outcomes are broadly associated with transplant recipients’ capacity in following a complex and continuous self-management regimen. Health information technology has the potential to empower patients. This systematic review aimed to determine the impacts of IT-based interventions for self-management in kidney transplant recipients.

Methods

A comprehensive investigation was performed in MEDLINE (via PubMed) and EMBASE (via Scopus) in April 2019. Eligible studies were the randomized controlled trials which aimed to design an automated IT-based intervention. All English papers including adult kidney transplant recipients were included. To assess the clinical trial’s quality, Cochrane Collaboration’s assessment tool was employed. The articles were integrated based on category of outcomes, characteristics of interventions, and their impact. The interventions were classified based on the used IT-based tools, including smart phones, coverage tools, computer systems, and a combination of several tools. The impact of interventions was defined as: (1) positive effect (i.e. statistically significant), and (2) no effect (i.e. not statistically significant).

Results

A total of 2392 articles were retrieved and eight publications were included for full-text analysis. Interventions include those involving the use of computerized systems (3 studies), smart phone application (3 studies), and multiple components (2 studies). The studies evaluated 30 outcomes in total, including 24 care process and 6 clinical outcomes. In 18 (80%) out of 30 outcomes, interventions had a statistically significant positive effect, 66% in process and 33% in clinical outcomes.

Conclusions

IT-based interventions (e.g. mobile health applications, wearable devices, and computer systems) can improve self-management in kidney transplant recipients (including clinical and care process outcomes). However, further evaluation studies are required to quantify the impact of IT-based self-management interventions on short- and long-term clinical outcomes as well as health care costs and patients' quality of life.

eHealth Interventions for Solid Organ Transplant Recipients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Lack of support for self-management may contribute to adverse health outcomes. eHealth has the potential to support self-management, but evidence in solid organ transplantation remains unclear. This review aims to evaluate the benefits and harms of eHealth interventions to support self-management in solid organ transplant recipients.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases for randomized trials of eHealth interventions in solid organ transplant recipients. We calculated the risk ratios or standardized mean difference of outcomes, and summary estimates were determined using random-effects models. The Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development, and Evaluations were used to assess trial quality.

RESULTS

Twenty-one trials from 6 countries involving 2114 participants were included. Compared with standard care, eHealth interventions improved medication adherence (risk ratio, 1.34; CI, 1.12-2.56; I = 75%) and self-monitoring behavior (risk ratio, 2.58; CI, 1.56-4.27; I = 0%) up to 12 mo posttransplant. The treatment effects were largely consistent across different subgroups except for intervention functionality and mode of delivery. The effects on other outcomes were uncertain. Nine trials reported harms. The overall risk of bias was considered high or unclear, and the quality of evidence was low to very low for all outcomes.

CONCLUSIONS

eHealth interventions may improve medication adherence and self-monitoring behavior in the short term, but high-quality intervention studies are needed to determine whether eHealth will improve long-term patient-relevant outcomes.

Describing barriers and facilitators for medication adherence and self-management among kidney transplant recipients using the information-motivation-behavioral skills model

BACKGROUND

We aimed to develop an adapted information-motivation-behavioral skills (IMB) model to describe barriers and facilitators for adherence and self-management among kidney transplant recipients.

METHODS

We conducted a review of literature about kidney transplant recipients' knowledge, perceptions, and experiences and organized our results using the IMB framework. We then conducted interviews with transplant recipients and transplant providers to supplement our literature search.

RESULTS

Our proposed adaption of the IMB model describes informational, motivational, and behavioral skills barriers and facilitators for medication adherence and self-management among kidney transplant recipients. Moderating factors influence not only behavioral skills, but also recipients' understanding of information and motivation to adhere and practice self-management.

CONCLUSION

By using the IMB model to organize current research and interviews with recipients and providers, we developed an adapted model for medication adherence and self-management. Results are promising to impact future educational and behavioral interventions for kidney transplant recipients.

Self-management and Related Psychosocial Variables Among Renal Transplant Patients

OBJECTIVE

To explore the influential factors of kidney transplant patients' self-management, especially psychosocial variables.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Questionnaires were administered to patients with the assistance of our team members to gather sociodemographic information, medical characteristics, self-management, social support, depression, and flourishing.

RESULTS

The study included 483 patients, 64.4% of whom were male. The score index of the total self-management scale was 81.95% and the "social psychology" dimension had the lowest index, at 75.63%. Higher scores for flourishing, shorter length of post-renal transplantation, more social support, lower body mass index, being female, and being employed were proved to be determinants of better self-management, and flourishing was identified as having the greatest influence. Some other indicators were also related to patients' self-management, particularly age, residence, income, hypertension, renal function, and depression.

CONCLUSION

The overall self-management of KT patients was middling, and the status of psychology management was not optimistic. This emphasized the importance of psychological intervention. For further exploration, flourishing was identified as contributing to better self-management, which implied that strengthening this factor could be another method of improving self-management, except that involves enhancing of social support and reducing depression. Age was also found to have differing degrees of influence on KT patients' self-management, which implies that younger patients should receive more support in self-management.

[Structural Equation Modeling of Self-Care Behaviors in Kidney Transplant Patients Based on Self-Determination Theory]

PURPOSE

The purpose of this study was to test a hypothesis explaining direct and indirect relationships among the factors affecting self-care behaviors of kidney transplant patients, based on self-determination theory.

METHODS

Data were collected from 222 outpatients with kidney transplantation. The endogenous and exogenous variables of the hypothetical model consisted of healthcare provider's autonomy support, duration after kidney transplantation, basic psychological need satisfaction, autonomous and controlled motivation, depression, and self-care behaviors. Collected data were analyzed using SPSS/WIN 24.0 and AMOS 24.0.

RESULTS

The hypothetical model demonstrated a good fit: RMSEA=.06, SRMR=.04, TLI=.94, CFI=.97. Statistically significant explanatory variables for the self-care behaviors of kidney transplant patients were duration after transplantation and basic psychological need satisfaction. Healthcare provider's autonomy support was indirectly significant, while autonomous motivation, controlled motivation and depression were not statistically significant for self-care behaviors. The variables accounted for 59.5% of the self-care behaviors of kidney transplant patients.

CONCLUSION

It is necessary to develop an autonomy support program for healthcare providers to enhance the self-care behaviors of kidney transplant patients. Preventing the deterioration of self-care behaviors will be possible by conducting this program at one year and six years post-transplantation. In addition, the results suggest the need to developing personalized autonomy support programs for healthcare providers that can meet the basic psychological need satisfaction of kidney transplant patients.

Effect of an interactive voice response system on self-management in kidney transplant recipients: Protocol for a randomized controlled trial

INTRODUCTION

Adherence to a complex and ongoing set of therapeutic recommendations significantly determines short and long-term outcomes after kidney transplantation (KT). Interactive voice response system (IVRS) is a novel phone-based platform which is potentially useful to deliver health behavior interventions.

OBJECTIVE

The aims of the study is to describe the development of a theory-driven and educational IVRS investigate the effect of an IVRS on the self-management outcomes in KT recipients as compared with the control group.

METHODS

This study has been designed as a randomized, 2 parallel groups controlled trial. The KT recipients' older than18 years of age with access to a cellphone will be included. A total of 120 patients will be randomly assigned to the control and intervention groups. The participants in the intervention group will receive completely automatic calls in 3 categories: educational, medication adherence, and reminders by the IVRS, whereas those in the control group will receive usual care. The follow up will be performed within 6 months. The primary outcome will be the medication adherence while patients' transplant knowledge, health-related quality of life, and rehospitalization rates will be considered as secondary outcomes.

RESULTS

Thus far, recruitment of participants has not been completed and results will be published in 2019.

DISCUSSION

The IVRS is potentially useful to help KT recipients improve the self-management outcomes. The hypothesis is using an IVRS intervention makes a significant difference between basel assessment of adherence to immunosuppressive medications scale, 12-item short form survey, second version, kidney transplant understanding tool baseline scores, and those obtained at the end of study.

TRIAL REGISTRATION NUMBER

This trial is registered with the Iran Trial Registrar under registration number IRCT20180124038492N1 and registration date 30 January 2018. https://irct.ir/trial/29215.

The Effect of Teach-Back Training on Self Management in Kidney Transplant Recipients: A Clinical Trial

BACKGROUND

Kidney transplant recipients need self-management during their lifetime, and training these patients is essential for the realization of self-management. Teach-back training (TBT) was used to receive, understand, and retain information. This study aimed to determine the effect of TBT on self-management in kidney transplant recipients.

METHODS

In this clinical trial study, 84 kidney transplant recipients who referred to the clinic of Imam Khomeini Hospital in Urmia (a city in northwest of Iran), from January to March 2017, were selected through convenience sampling and randomly assigned to intervention and control groups. In the intervention group, educational content was presented for each patient with TBT in 5 sessions of 60 minutes. Data were collected before and after the intervention by a special Self-Management Questionnaire for Kidney Transplant Recipients in five areas as follows: self-monitoring, self-care behavior in daily living, early detecting and coping with abnormalities after kidney transplantation, stress management and the category of non-categorized area. This is a valid and reliable questionnaire (α=0.76). Collected data were analyzed by independent t-test and Mann-Whitney test. Statistical analysis was performed using SPSS 20 and P≤0.05 was considered as significant.

RESULTS

Independent t-test showed that the mean of self-management score between the control and intervention groups was not statistically significant before the intervention (P=0.90). The mean score of self-management increased after implementation of TBT in the intervention group compared to the control group, and the difference was statistically significant (P=0.001).

CONCLUSION

The implementation of TBT method is effective in promoting self-management of kidney transplant recipients. Therefore, it is recommended that this method should be used to train the patients to better understand the components of self-management. Trial Registration Number: IRCT2016122817059N10.

Outcome disparities between African Americans and Caucasians in contemporary kidney transplant recipients

BACKGROUND

Racial disparities in African-American (AA) kidney transplant have persisted for nearly 40 years, with limited data available on the scope of this issue in the contemporary era of transplantation.

METHODS

Descriptive retrospective cohort study of US registry data including adult solitary kidney transplants between Jan 1, 2005 to Dec 31, 2009.

RESULTS

60,695 recipients were included; 41,426 Caucasians (68%) and 19,269 AAs (32%). At baseline, AAs were younger, had lower college graduation rates, were more likely to be receiving public health insurance and have diabetes. At one-year post-transplant, AAs had 62% higher risk of graft loss (RR 1.62, 95% CI 1.50-1.75) which increased to 93% at five years (RR 1.93, 95% CI 1.85-2.01). Adjusted risk of graft loss, accounting for baseline characteristics, was 60% higher in AAs (HR 1.61 [1.52-1.69]). AAs had significantly higher risk of acute rejection and delayed graft function.

CONCLUSION

AAs continue to experience disproportionately high rates of graft loss within the contemporary era of transplant, which are related to a convergence of an array of socioeconomic and biologic risk factors.

Role of in-hospital care quality in reducing anxiety and readmissions of kidney transplant recipients

BACKGROUND

A total of 17,000 patients receive kidney transplants each year in the United States. The 30-day readmission rate for kidney transplant recipients is over 30%. Our research focuses on the relationship between the quality of care delivered during the patient's hospital stay for a kidney transplant, and the patient health outcomes and readmissions related to the transplant.

METHODS

We interviewed 20 kidney transplant recipients at a major transplant center in the United States. Findings from these interviews were used to inform the data collection using structured surveys, which were administered to an additional 77 kidney transplant recipients. We used ordinary least squares regression to predict the effects of two dimensions of in-hospital care quality-information consistency and empathetic care delivery-on level of patient anxiety 1 week following discharge. Further, we estimated a logistic regression to predict the effect of anxiety, combined with the two dimensions of in-hospital care quality, on occurrence of 30-day readmissions.

RESULTS

Patient anxiety levels 1 wk after discharge are significantly associated with information consistency and empathetic delivery of care. Patient anxiety 1 wk after discharge is associated with occurrence of 30-d readmissions. The logistic regression model indicates that the risk of getting readmitted is 110% higher for a one unit increase in patient anxiety level 1 wk after discharge. Finally, patient anxiety fully mediates the effects of consistency of information and empathetic care delivery on occurrence of 30-d readmissions (50.96% of the effect is mediated).

CONCLUSIONS

Our study suggests two ways of preventing readmissions through reduction of postdischarge anxiety: (1) standardizing in-hospital care, so that information received by patients is consistent, and (2) by training caregivers to be more empathetic toward patients during the delivery of this information.

Patients' experiences from their received education about the process of kidney transplant: A qualitative study

BACKGROUND

Kidney transplant needs long term treatment, care and a follow up. Patients with kidney transplant need support in fields of knowledge, skills and motivations. Several researches showed existing challenges regarding education of these patients. A qualitative study was conducted to define patients' experiences from their received education about the process of kidney transplant.

MATERIALS AND METHODS

This was a qualitative study with a content analysis approach. Sampling was purposive up to data saturation. The participants aged 18-60 years, had experienced transplantation. The data were collected by semi-structural individual in-depth interviews with 18 participants. The interviews were analyzed by Graneheim and Lundman content analysis method.

FINDINGS

Three general themes of "educational experiences at the beginning of transplantation", "educational experiences in post transplantation care", and "patients' struggle to enhance their awareness in order to preserve their transplanted kidney" were emerged.

CONCLUSIONS

The findings showed that patients' did not receive adequate knowledge about kidney transplant process. This issue reveals an unstructured and uncoordinated education given to kidney transplant patients by health team members during kidney transplant process. With regard to high motivation of the patients, designing such educational program based on self-management in the process of kidney transplant for these recipients is essential. Nurses in their educational role can enable the patients through educating them about problem solving methods and selection of the best solution to preserve their transplanted kidney and consider renal transplant recipient self-management as their first priority toward these patients.

A systematic approach to postoperative management of deceased donor kidney transplant patients with a clinical pathway

CONTEXT

Clinical pathways have been used in many acute hospital settings.

OBJECTIVES

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

DESIGN AND SETTING

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

MAIN OUTCOME MEASURES

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

RESULTS

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

A Systematic Approach to Postoperative Management of Deceased Donor Kidney Transplant Patients with a Clinical Pathway

Context

Clinical pathways have been used in many acute hospital settings.

Objectives

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

Design and Setting

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

Main Outcome Measures

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

Results

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

Comparison of the ICF core set for cardiopulmonary conditions in the acute hospital setting among different types of transplant patients

To compare the functioning profiles of patients receiving different types of organ transplants using the International Classification of Functioning, Disability, and Health. The patients (n =102) were enrolled between days 5 and 10 after discharge following receipt of an organ transplant,and assessed for sociodemographic variables, the Functional Independence Measure and Barthel Index, and the International Classification of Functioning, Disability,and Health core set for cardiopulmonary conditions in the acute hospital, augmented with three additional categories.Analysis was conducted by grouping the patients as follows: (1) kidney transplants; (2) all other kinds of transplants. Functional Independence Measure/Barthel Index scores were significantly higher in group 1 compared with group 2. Prevalences of 30% or greater for any impairment were noted for seven b factors, one s factor,and one d factor in group 1, whereas the corresponding numbers for group 2 were 14, 2, and 8, respectively. When prevalences of 30% or greater were calculated for severe or total impairment for all factors, there were none for group 1, but six factors for group 2. For the six factors, the prevalence difference between the groups was significant in five after a full Bonferroni correction (P < 0.000002). The factors with the highest barriers were e110 (products or substances for personal consumption, 36%) and e120(products and technology for personal use in daily living,42%) in group 2 (both significant with P < 0.000001 when compared with the respective prevalences in group 1).Although exercise seems to be the most needed rehabilitation function for kidney transplant patients, other transplant patients will require considerably more rehabilitation intervention.

Chronic illness self-care and the family lives of older adults: a synthetic review across four ethnic groups

The purpose of this paper is to integrate the literature on family and social ties among older ethnic minority men and women with the literature on chronic illness self-care among elders in these groups, in order to increase understanding of social influences on self-care behavior, raise questions for future research, and inform culturally appropriate interventions to maximize the health-promoting potential of social relationships. The paper presents demographic and chronic illness prevalence information, and then summarizes literature about patterns of chronic illness self-care behaviors for older African-Americans, Latinos, Asian-Americans, and American Indians in the U.S. For each group, the sociological literature about residential, cultural, and socioeconomic patterns, family lives, and other social ties is then reviewed, and the self-care literature that has accounted for these patterns is discussed. Finally, six themes are outlined and related questions are identified to further illuminate the social context of older adults' chronic illness self-care.

Disparities in kidney transplant outcomes: a review

Sociocultural and socioeconomic disparities in graft survival, graft function, and patient survival in adult kidney transplant recipients are reviewed. Studies consistently document worse outcomes for black patients, patients with low income, and patients with less education, whereas better outcomes are reported in Hispanic and Asian kidney transplant recipients. However, the distinct roles of racial/ethnic versus socioeconomic factors remain unclear. Attention to potential pathways contributing to disparities has been limited to immunologic and nonimmunologic factors, for which the mechanisms have yet to be fully illuminated. Interventions to reduce disparities have focused on modifying immunosuppressant regimens. Modifying access to care and health care funding policies for immunosuppressive medication coverage also are discussed. The implementation of culturally sensitive approaches to the care of transplant candidates and recipients is promising. Future research is needed to examine the mechanisms contributing to disparities in graft survival and ultimately to intervene effectively.

Integrating wellness, recovery, and self-management for mental health consumers

Three distinct, yet interrelated, terms-wellness, recovery, and self-management-have received increasing attention in the research, consumer, and provider communities. This article traces the origins of these terms, seeking to understand how they apply, individually and in conjunction with one another to mental health consumers. Each shares a common perspective that is health-centered rather than disease-centered and that emphasizes the role of consumers as opposed to professional providers as the central determinants of health and well-being. Developing approaches combining elements of each construct may hold promise for improving the overall health and well-being of persons with serious mental disorders.

Patient adherence or patient self-management in transplantation: an ethical analysis

Adherence of patients to transplantation regimens has been problematic. Patient self-management of the chronic diseases that frequently lead to transplantation is now the standard of practice, although that practice has been incompletely implemented. Through its focus on developing patients' skills and confidence in their ability to perform medical management, maintain important life roles, and manage the negative emotions that often accompany chronic conditions, patient self-management has the potential to support effective adherence of patients in an ethically satisfactory way. A professional decision to transplant should carry with it a commitment to help patients self-manage, including patients with low levels of literacy. Viewing adherence as patients' work to be accomplished within a framework of patient self-management offers an option for improving transplant outcomes. Testing this option is an important next step.

Interventions to improve medication-adherence after transplantation: a systematic review

Reports of interventions to improve adherence to medical regimens in solid organ transplant recipients are scarce. A systematic review identified 12 intervention studies. These studies focused on renal, heart, and liver transplant recipients. Five reports used randomized controlled trial (RCT) designs. Sample sizes varied between 18 and 110 subjects. The interventions are difficult to evaluate and categorize because of brief descriptions of intervention details. Of the 12 studies identified in this review, only five studies found a statistically significant improvement in at least one medication-adherence outcome with the intervention. In general, most included a combination of patient-focused cognitive/educational, counseling/behavioral, and psychologic/affective dimensions. Eight studies intervened at the healthcare provider, healthcare setting or healthcare system level, but showed a limited improvement in adherence. No single intervention proved to be superior at increasing medication-adherence in organ transplantation, but a combination of interventions in a team approach for the chronic disease management of organ transplant patients may be effective in a long-term perspective. In conclusion, finding the most effective combination of interventions to enhance adherence is vital. Utilizing an RCT design and adhering to the CONSORT guidelines can lead to higher quality studies and possibly more effective intervention studies to enhance medication-adherence.

Patient Adherence or Patient Self-Management in Transplantation: An Ethical Analysis

Adherence of patients to transplantation regimens has been problematic. Patient self-management of the chronic diseases that frequently lead to transplantation is now the standard of practice, although that practice has been incompletely implemented. Through its focus on developing patients' skills and confidence in their ability to perform medical management, maintain important life roles, and manage the negative emotions that often accompany chronic conditions, patient self-management has the potential to support effective adherence of patients in an ethically satisfactory way. A professional decision to transplant should carry with it a commitment to help patients self-manage, including patients with low levels of literacy. Viewing adherence as patients' work to be accomplished within a framework of patient self-management offers an option for improving transplant outcomes. Testing this option is an important next step.

Computerized patient education in kidney transplantation: testing the content validity and usability of the Organ Transplant Information System (OTIS)

OBJECTIVE

To test content validity and usability of the Organ Transplant Information System (OTIS).

METHODS

This study used qualitative methods. The purposive sample consisted of 8 clinicians and 14 patients. Clinicians rated the content's congruence with current medical practice. We used the clinicians' evaluations to revise the OTIS content; then each patient evaluated the revised OTIS modules using the thinking-aloud method and via structured interviews. Descriptive statistics were applied for demographic and clinical data, and for the clinicians' ratings. Content data usability and validity were analyzed using Content Analysis.

RESULTS

Clinicians identified deviations from current medical practice regarding content, language, and information structure of OTIS. Seven rated OTIS as non-relevant for implementation into clinical practice. Five rated the program's content--with the stipulated adaptations--as important for patients. All patients encountered usability problems, mostly regarding the program's interface. Emerging categories from the patients' perspectives vis à vis content were knowledge acquisition, illness management, and partnership forming.

CONCLUSION

Problems arose regarding OTIS's initial content validity and usability, demonstrating the need to establish the presented material's content validity and usability by involving clinicians and patients before its clinical implementation.

PRACTICE IMPLICATIONS

High quality computer-learning-software is needed to enhance patient self-management.

Adherence to immunosuppression: a prospective diary study

Immunosuppression adherence among kidney transplant recipients is essential for graft survival. However, nonadherence is common, jeopardizing graft survival. Besides skipping dosages, little is known about other forms of medication nonadherence and their underlying reasons. This study sought to examine patients' extent of medication adherence over time and reasons for nonadherence. Thirty-nine new kidney transplant recipients were asked to complete a month-long medication-taking diary that included reporting medication nonadherence such as skipped medications, medications taken early or late, taking dosages greater or less than prescribed, and the reason for each occurrence of nonadherence. Of the 20 (51%) patients who completed the diary, 11 (55%) reported at least 1 form of nonadherence. Eleven patients reported taking their immunosuppression at least 1 hour later than the prescribed time, 1 patient reported skipping medication, but no patients reported changing the dosage on their own. Immunosuppression was taken on average 1.5 hours after the prescribed time. Of those patients who took their medications late, there were on average 3.1 occasions of taking it late. The most common reasons for this behavior included health care-related issues, followed by oversleeping, being away from home, work-related barriers, and forgetting. The majority of kidney transplant recipients took medications later than prescribed during 1 month. Future research should determine the clinical impact on graft function of late administration of immunosuppression. Interventions should be designed to better assist kidney recipients with taking medications on time, especially when they are away from home.

Responsibility for control; ethics of patient preparation for self-management of chronic disease

Patient self-management (SM) of chronic disease is an evolving movement, with some forms documented as yielding important outcomes. Potential benefits from proper preparation and maintenance of patient SM skills include quality care tailored to the patient's preferences and life goals, and increase in skills in problem solving, confidence and success, generalizable to other parts of the patient's life. Four central ethical issues can be identified. 1) insufficient patient/family access to preparation that will optimize their competence to SM without harm to themselves, 2) lack of acknowledgement that an ethos of patient empowerment can mask transfer of responsibility beyond patient/family competency to handle that responsibility, 3) prevailing assumptions that preparation for SM cannot result in harm and that its main purpose is to deliver physician instructions, and 4) lack of standards for patient selection, which has the potential to exclude individuals who could benefit from learning to SM. Technology assessment offers one framework through which to examine available data about efficacy of patient SM and to answer the central question of what conditions must be put in place to optimize the benefits of SM while assuring that potential harms are controlled.

The economics and ethics of kidney transplantation: perspectives in 2006

PURPOSE OF REVIEW

The field of kidney transplantation has made impressive progress, which has led to marked improvements in both patient and allograft survival. The economic and ethical consequences of these advances have recently garnered increasing attention in the medical literature. This review highlights key articles published in 2005 and 2006.

RECENT FINDINGS

Major areas of focus in the health economics literature pertaining to kidney transplantation include the most cost-effective strategies for immunosuppressive therapies, the management of posttransplant complications, and the optimal utilization of the current pool of deceased-donor kidneys. Ethical challenges include various aspects of living donation, strategies to expand the donor pool, and the impact of financial policies for immunosuppressive agents on long-term patient and allograft survival.

SUMMARY

Given the rising demand for kidney transplantation within a setting of scarce resources, the economic and ethical dimensions of transplant medicine are of increasing interest to patients, providers, and payers. Research in these areas will help uncover ways to utilize this important medical technology in the most ethical and cost-effective manner.

Supporting medication adherence in renal transplantation (SMART): a pilot RCT to improve adherence to immunosuppressive regimens

BACKGROUND

Although non-adherence to an immunosuppressive regimen (NAH) is a major risk factor for poor outcome after renal transplantation (RTx), very few studies have examined non-adherence intervention in this context. This pilot randomized controlled trial (RCT) tested the efficacy of an educational-behavioural intervention to increase adherence in non-adherent RTx patients. We also assessed how NAH evolves over time.

METHODS

Eighteen RTx non-adherent patients (age: 45.6 +/- 1.2 yr; 78.6% male) were randomly assigned to either an intervention group (IG) (n = 6) or an enhanced usual care group (EUCG) (n = 12), the latter receiving the usual clinical care. The IG received one home visit and three telephone interviews. We assessed NAH through electronic monitoring (EM) of medication intake during a nine-month period (three months intervention, six months follow-up).

RESULTS

Five of 18 patients withdrew. Inclusion in the study resulted in a remarkable decrease in NAH in both groups over the first three months (IG chi(2) = 3.97, df = 1, p = 0.04; EUCG chi(2) = 3.40, df = 1, p = 0.06). The IG showed the greatest decrease in NAH after three months, although this did not reach statistical significance (at 90 d, chi(2) = 1.05, df = 1, p = 0.31). Thereafter, NAH increased gradually in both groups, reaching comparable levels at the end of the six-month follow-up (i.e. at nine months).

CONCLUSION

Our findings suggest an inclusion effect. Although the intervention in this pilot RCT appeared to add further benefit in medication compliance, a lack of statistical power prevented us from making a strong statistical statement.

Pretransplant physical functioning and kidney patients' risk for posttransplantation hospitalization/death: evidence from a national cohort

Patient physical functioning level is an indicator of medical fitness that may predict outcomes after kidney transplantation. A small study of patients at a single center found a correlation between patient-rated physical functioning pretransplantation and the number of emergency hospital visits posttransplantation. In a national multicenter cohort, the association of incident dialysis patients' physical functioning scores with their risk for posttransplantation all-cause hospitalization/death was investigated using Cox proportional hazards analysis. The study cohort included patients who participated in the Dialysis Morbidity and Mortality Study (DMMS) Wave 2 and received a first transplant no more than 24 mo after treatment start. Updated patient information was available in the 2004 United States Renal Data System Standard Analysis Files. Higher pretransplantation physical functioning score was found to be a significant predictor of transplant recipients' reduced risk for hospitalization/death. Patients in the Cox model who were aged 55+ had increased risk for hospitalization/death. Gender, race, diabetic ESRD, and cardiovascular comorbidity were NS predictors. A potential explanation for the ability of the Medical Outcomes Study Short-Form 36 physical functioning measure to predict risk for posttransplantation morbidity/mortality is that physical activity/exercise behavior is likely to be closely associated with an individual's physical functioning level, and pretransplantation activity levels may be indicative of lifestyle habits that continue to influence patient behavior posttransplantation. More research investigating patients' pre- and posttransplantation physical functioning levels in relation to transplant outcomes would be valuable.