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Yang N, Vittorio J, King LY. Pediatric liver transplant recipients are not just young adults: The importance of a structured health care transition program in adult transplant centers. Liver Transpl 2024; 30:945-959. [PMID: 38915180 DOI: 10.1097/lvt.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/25/2024] [Indexed: 06/26/2024]
Abstract
Health care transition (HCT) is a vulnerable period that continues into adulthood, even after the transfer of care. Given the growing population of pediatric liver transplant recipients reaching young adulthood, the need for a standardized and multidisciplinary approach to transition that spans from pediatric to adult care is becoming more imperative. In this article, we review the unique challenges and barriers to successful HCT that adolescent and young adults (AYAs) who have undergone liver transplant face, highlight the gap in transition care in the adult setting, and present the Six Core Elements of Health Care Transition TM as a framework that can be used by adult providers to incorporate AYAs systematically and collaboratively into adult practice. Multidisciplinary HCT programs should be the standard of care for all AYAs with liver transplant, and while implementation is a necessary first step, ongoing efforts to increase awareness, funding, and research on HCTs into adulthood are needed.
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Affiliation(s)
- Nancy Yang
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, NYU Langone Health, New York, New York, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
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2
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Vittorio J, Kosmach-Park B, Wadhwani S, Jackson W, Kerkar N, Corbo H, Vekaria P, Gupta N, Yeh H, King LY. Adult provider role in transition of care for young adult pediatric recipients of liver transplant: An expert position statement. Hepatol Commun 2024; 8:e0486. [PMID: 39023314 PMCID: PMC11262821 DOI: 10.1097/hc9.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 07/20/2024] Open
Abstract
Health care transition (HCT) is the process of changing from a pediatric to an adult model of care. Young adult pediatric recipients of liver transplant transferring from pediatric to adult health care services are highly vulnerable and subject to poor long-term outcomes. Barriers to successful transition are multifaceted. A comprehensive HCT program should be initiated early in pediatrics and continued throughout young adulthood, even after transfer of care has been completed. It is critical that pediatric and adult liver transplant providers establish a partnership to optimize care for these patients. Adult providers must recognize the importance of HCT and the need to continue the transition process following transfer. While this continued focus on HCT is essential, current literature has primarily offered guidance for pediatric providers. This position paper outlines a framework with a sample set of tools for the implementation of a standardized, multidisciplinary approach to HCT for adult transplant providers utilizing "The Six Core Elements of HCT." To implement more effective strategies and work to improve long-term outcomes for young adult patients undergoing liver transplant, HCT must be mandated as a routine part of posttransplant care. Increased advocacy efforts with the additional backing and support of governing organizations are required to help facilitate these practices.
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Affiliation(s)
- Jennifer Vittorio
- Department of Pediatrics, New York University (NYU) Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Beverly Kosmach-Park
- Department of Transplant Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sharad Wadhwani
- Department of Pediatrics, University of California-San Francisco, San Francisco, California, USA
| | - Whitney Jackson
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nanda Kerkar
- Department of Pediatrics, University of Rochester Medical Center, New York, New York, USA
| | - Heather Corbo
- Department of Pharmacy, New York-Presbyterian Hospital, New York, New York, USA
| | - Pooja Vekaria
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Nitika Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Heidi Yeh
- Division of Transplant Surgery, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
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Joshi D, Nayagam J, Clay L, Yerlett J, Claridge L, Day J, Ferguson J, Mckie P, Vara R, Pargeter H, Lockyer R, Jones R, Heneghan M, Samyn M. UK guideline on the transition and management of childhood liver diseases in adulthood. Aliment Pharmacol Ther 2024; 59:812-842. [PMID: 38385884 DOI: 10.1111/apt.17904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/15/2023] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Improved outcomes of liver disease in childhood and young adulthood have resulted in an increasing number of young adults (YA) entering adult liver services. The adult hepatologist therefore requires a working knowledge in diseases that arise almost exclusively in children and their complications in adulthood. AIMS To provide adult hepatologists with succinct guidelines on aspects of transitional care in YA relevant to key disease aetiologies encountered in clinical practice. METHODS A systematic literature search was undertaken using the Pubmed, Medline, Web of Knowledge and Cochrane database from 1980 to 2023. MeSH search terms relating to liver diseases ('cholestatic liver diseases', 'biliary atresia', 'metabolic', 'paediatric liver diseases', 'autoimmune liver diseases'), transition to adult care ('transition services', 'young adult services') and adolescent care were used. The quality of evidence and the grading of recommendations were appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS These guidelines deal with the transition of YA and address key aetiologies for the adult hepatologist under the following headings: (1) Models and provision of care; (2) screening and management of mental health disorders; (3) aetiologies; (4) timing and role of liver transplantation; and (5) sexual health and fertility. CONCLUSIONS These are the first nationally developed guidelines on the transition and management of childhood liver diseases in adulthood. They provide a framework upon which to base clinical care, which we envisage will lead to improved outcomes for YA with chronic liver disease.
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Affiliation(s)
- Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Jeremy Nayagam
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Lisa Clay
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
| | - Jenny Yerlett
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
| | - Lee Claridge
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Jemma Day
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Ferguson
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Paul Mckie
- Department of Social Work, King's College Hospital NHS Foundation Trust, London, UK
| | - Roshni Vara
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
- Evelina London Children's Hospital, London, UK
| | | | | | - Rebecca Jones
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Michael Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
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Turner EM, Cassidy AR, Rea KE, Smith-Paine JM, Wolfe KR. [Formula: see text] The multifaceted role of neuropsychology in pediatric solid organ transplant: preliminary guidelines and strategies for clinical practice. Child Neuropsychol 2024; 30:503-537. [PMID: 37291962 DOI: 10.1080/09297049.2023.2221759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/31/2023] [Indexed: 06/10/2023]
Abstract
The incidence of pediatric solid organ transplantation (SOT) has increased in recent decades due to medical and surgical advances as well as improvements in organ procurement. Survival rates for pediatric kidney, liver, and heart transplantation are above 85% but patients continue to experience complex healthcare needs over their lifetime. Long-term developmental and neuropsychological sequelae are becoming increasingly recognized in this population, although preliminary work is limited and deserves further attention. Neuropsychological weaknesses are often present prior to transplantation and may be related to underlying congenital conditions as well as downstream impact of the indicating organ dysfunction on the central nervous system. Neuropsychological difficulties pose risk for functional complications, including disruption to adaptive skill development, social-emotional functioning, quality of life, and transition to adulthood. The impact of cognitive dysfunction on health management activities (e.g., medication adherence, medical decision-making) is also an important consideration given these patients' lifelong medical needs. The primary aim of this paper is to provide preliminary guidelines and clinical strategies for assessment of neuropsychological outcomes across SOT populations for pediatric neuropsychologists and the multidisciplinary medical team, including detailing unique and shared etiologies and risk factors for impairment across organ types, and functional implications. Recommendations for clinical neuropsychological monitoring as well as multidisciplinary collaboration within pediatric SOT teams are also provided.
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Affiliation(s)
- Elise M Turner
- Department of Pediatrics, Section of Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Cassidy
- Departments of Psychiatry & Psychology and Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly E Rea
- Division of Pediatric Psychology, Department of Pediatrics, C. S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Julia M Smith-Paine
- Division of Developmental-Behavioral Pediatrics & Psychology, Department of Pediatrics, Rainbow Babies & Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kelly R Wolfe
- Department of Pediatrics, Section of Neurology, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, CO, USA
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Beath SV, Taylor Z, Wray J, Passingham C, Lloyd C, Kelly DA. Long-Term Cognitive Outcomes and Associated Quality of Life of Young Adults Who Experienced Liver Transplantation in Early Childhood. FRONTIERS IN TRANSPLANTATION 2022; 1:919232. [PMID: 38994390 PMCID: PMC11235375 DOI: 10.3389/frtra.2022.919232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/24/2022] [Indexed: 07/13/2024]
Abstract
We evaluated long term outcomes in infants born between 1992 and 2002 with cholestatic liver disease (CLD) who underwent successful liver transplantation (LT). A total of 160 children with CLD were identified: 68 had developmental assessments before and after LT of whom 32 were excluded because they were followed up elsewhere; 16/36 consented to complete measures of IQ, anxiety, depression, health related quality of life (HRQoL), and a habits/employment survey. Illness severity and developmental attainment prior to LT were comparable with the 32 excluded and 20 patients who declined to take part. The IQ of young adults after LT (mean score = 91.13, range 75-108, SD 10.4) was not significantly improved compared to pre-LT scores (mean score = 85.7 range 50-111, SD 17), but was inversely correlated with stunting of growth and duration of disease before LT, highlighting the need for timely LT in CLD. HRQoL scores ranged from 22 to 99 (mean 64.5 SD 20.7), comparable to scores in other LT recipients. Five (31%) had mild-moderate depression; 5 (31%) had moderate-severe anxiety associated with reduced HRQoL (P = 0.01 and P = 0.06, respectively); and nine had problematic fatigue which correlated with reduced HRQoL (r 2 = 0.4 P = 0.007). Reduced medication adherence was associated with fatigue (Spearman correlation r 2 = 0.267; P = 0.09) and anxiety (Spearman correlation r 2 = 0.597; P = 0.02). Raised body mass index was also associated with reduced and health-related quality of life scores PeLTQL© (r 2 = 0.379 P = 0.011). Fifteen (94%) were undergoing education or were employed. The long-term neuro-cognitive and psychosocial outcomes of young adults transplanted as babies is encouraging, although anxiety/depression was more common than in the healthy population. Psychosocial questionnaires help identify those young adult LT recipients who may benefit from support.
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Affiliation(s)
- Sue V. Beath
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Zoe Taylor
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Charlotte Passingham
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Carla Lloyd
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Deirdre A. Kelly
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
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Palman J, McDonagh JE. Young Minds: Mental Health and Transitional Care in Adolescent and Young Adult Rheumatology. Open Access Rheumatol 2020; 12:309-321. [PMID: 33324121 PMCID: PMC7732171 DOI: 10.2147/oarrr.s228083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/11/2020] [Indexed: 12/27/2022] Open
Abstract
Consideration of the mental health and emotional wellbeing is an important component of health care for all young people, irrespective of setting. Mental health disorders are common during adolescence and young adulthood and young people with rheumatic musculoskeletal diseases (RMD) are not exempt. For such young people, risks of poor outcomes are related to both mental health as well as their RMD. Times of change during adolescence and young adulthood-transitions-are potentially vulnerable life stages for young people with RMD and warrant specific attention in health care provision. Such transitions include those occurring at puberty, during education, training, and employment, socially with moves away from the parental home, as well as from child to adult-centered health services. There is great potential for rheumatology professionals to support young people with RMD at these transitions in view of their frequent encounters and ongoing therapeutic relationships. In this review, we aim to assess the impact of mental health on RMD during adolescence and young adulthood with particular reference to transitional care provision and how rheumatology professionals can be involved in addressing mental health issues during this time of change.
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Affiliation(s)
- Jason Palman
- Department of Paediatric and Adolescent Rheumatology, Royal Manchester Children’s Hospital, Manchester University Hospitals NHS Trust, ManchesterM13 9WL, UK
| | - Janet E McDonagh
- Department of Paediatric and Adolescent Rheumatology, Royal Manchester Children’s Hospital, Manchester University Hospitals NHS Trust, ManchesterM13 9WL, UK
- Versus Arthritis Centre for Epidemiology; Centre for MSK Research, University of Manchester, Manchester, UK
- NIHR Biomedical Research Centre, Manchester University Hospital NHS Trust, Manchester, UK
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Campagna BR, Weatherley K, Shemesh E, Annunziato RA. Adherence to Medication During Transition to Adult Services. Paediatr Drugs 2020; 22:501-509. [PMID: 32889685 PMCID: PMC7474320 DOI: 10.1007/s40272-020-00414-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The transition from childhood and adolescence to adulthood is often tumultuous. For individuals with a chronic medical condition, this progression also includes a gradual transition to independence in healthcare management as well as a transfer in care location at some set point. As adolescents navigate these sometimes challenging processes, there is a significant risk for a decline in adequate health behaviors, which can have dire consequences. One of the most vital components of the transfer to adult care is medication adherence. Poor medication adherence puts patients at risk for worse outcomes, with the most profound being increased mortality for many conditions. In recent years, acknowledgment of the need to create evidence-based methods to aid patients during the transition period has been growing. This paper seeks to provide an overview of current research and recommendations for interventions to increase adherence to medication regimens during this period.
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Affiliation(s)
- Bianca R. Campagna
- grid.256023.0000000008755302XDepartment of Psychology, Fordham University, 441 E. Fordham Road, Bronx, NY 10458 USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Kristen Weatherley
- grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Eyal Shemesh
- grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
| | - Rachel A. Annunziato
- grid.256023.0000000008755302XDepartment of Psychology, Fordham University, 441 E. Fordham Road, Bronx, NY 10458 USA ,grid.59734.3c0000 0001 0670 2351Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children’s Hospital, New York, NY USA
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8
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Beath SV, Wray J. Health-Related Quality of Life and Cognitive Functioning in Pediatric Liver Transplant Recipients. Liver Transpl 2020; 26:9-11. [PMID: 31758831 DOI: 10.1002/lt.25687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Sue V Beath
- The Liver Unit, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children, National Health Service Foundation Trust, London, United Kingdom
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Pediatric Heart Transplantation: Transitioning to Adult Care (TRANSIT): Feasibility of a Pilot Randomized Controlled Trial. J Card Fail 2019; 25:948-958. [PMID: 31276804 DOI: 10.1016/j.cardfail.2019.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Young-adult heart transplant recipients transferring to adult care are at risk for poor health outcomes. We conducted a pilot randomized controlled trial to determine the feasibility of and to test a transition intervention for young adults who underwent heart transplantation as children and then transferred to adult care. METHODS Participants were randomized to the transition intervention (4 months long, focused on heart-transplant knowledge, self-care, self-advocacy, and social support) or usual care. Self-report questionnaires and medical records data were collected at baseline and 3 and 6 months after the initial adult clinic visit. Longitudinal analyses comparing outcomes over time were performed using generalized estimating equations and linear mixed models. RESULTS Transfer to adult care was successful and feasible (ie, excellent participation rates). The average patient standard deviation of mean tacrolimus levels was similar over time in both study arms and < 2.5, indicating adequate adherence. There were no between-group or within-group differences in percentage of tacrolimus bioassays within target range (> 50%). Average overall adherence to treatment was similarly good in both groups. Rates of appointment keeping through 6 months after transfer declined over time in both groups. CONCLUSIONS The feasibility of the study was demonstrated. Our transition intervention did not improve outcomes.
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Hames A, Matcham F, Joshi D, Heneghan MA, Dhawan A, Heaton N, Samyn M. Liver transplantation and adolescence: The role of mental health. Liver Transpl 2016; 22:1544-1553. [PMID: 27597423 DOI: 10.1002/lt.24629] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/11/2016] [Accepted: 08/16/2016] [Indexed: 02/07/2023]
Abstract
Young people (YP) with chronic illness have higher rates of mental health problems than the general population, with psychosocial complexity associated with nonadherence and poorer health outcomes. This study aimed to describe the prevalence of anxiety and depression in YP after liver transplantation, with autoimmune liver disease and other chronic liver diseases, identify the factors YP attribute their distress to and the relationship between anxiety/depression, and describe YP's beliefs about their illness and treatment. An electronically administered questionnaire battery was given routinely to YP attending an outpatient liver transition clinic; 187 YP participated, of which 17.7% screened positive for anxiety or depression. There were no significant differences between disease groups. This is significantly higher than the prevalence of common mental health problems in the general adolescent population. Patients most frequently attributed their distress to fatigue, sleep difficulties, financial concerns, problems at work/school, worry, and low self-esteem. Higher levels of depression and anxiety were significantly associated with specific illness and treatment beliefs but not with perceived understanding of illness or treatment control. In conclusion, the increased prevalence of mental health problems in YP and the intertwined nature of these with their physical health outcomes provide evidence that holistic care should be delivered as standard for this age group. Liver Transplantation 22 1544-1553 2016 AASLD.
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Affiliation(s)
- Anna Hames
- Institute of Liver Studies, National Health Service Foundation Trust, London, United Kingdom.
| | - Faith Matcham
- Department of Psychological Medicine, National Health Service Foundation Trust, London, United Kingdom
| | - Deepak Joshi
- Institute of Liver Studies, National Health Service Foundation Trust, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, National Health Service Foundation Trust, London, United Kingdom
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, National Health Service Foundation Trust, London, United Kingdom
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, United Kingdom
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Muduma G, Shupo FC, Dam S, Hawken NA, Aballéa S, Odeyemi I, Toumi M. Patient survey to identify reasons for non-adherence and elicitation of quality of life concepts associated with immunosuppressant therapy in kidney transplant recipients. Patient Prefer Adherence 2016; 10:27-36. [PMID: 26834463 PMCID: PMC4716768 DOI: 10.2147/ppa.s96086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Renal transplantation (RT) is considered the treatment of choice for end-stage renal disease compared to dialysis, offering better health-related quality of life (HRQoL) and higher survival rates. However, immunosuppressants are essential for the long-term survival of kidney grafts and patients' non-adherence to their medication leads to poor outcomes. Immunosuppressants can also significantly alter patients' HRQoL because of their side effects and the complex chronic medication regimen they represent. PURPOSE To elicit key concepts related to adherence to immunosuppressant therapy (IT) and reasons for non-adherence in terms of patient reported outcomes, side effects, and the impact of the medication on HRQoL in RT population, including patient preference of once daily over twice-daily immunosuppressive regimen. Results were used to develop an IT-specific conceptual framework and provide suggestions for improving patients' adherence to IT. MATERIALS AND METHODS Interviews were conducted with three clinical experts to determine key concepts related to RT and immunosuppressants. Thirty-seven participants in four focus groups were asked to cite important concepts related to adherence and impact of IT on HRQoL and to rate them. Qualitative analysis was conducted to code participants' responses. RESULTS Non-adherence among participants where admitted was unintentional. The reason for this included forgetfulness, interference with lifestyle, being asleep at the time the medication should be taken, change in routine, and impact of side effects. Overall, participants reported that the evening dose was more problematic to remember and that the exclusion of this dose could make them more adherent. Participants also reported that IT impacted on their HRQoL in a number of ways including: placing restrictions on their lifestyle, causing anxiety, or impairing their ability to work. CONCLUSION This study provides qualitative evidence about the barriers to IT adherence and the components of HRQoL that are important from the perspective of RT patients. The developed conceptual framework of IT-HRQoL in RT transplants, including social, psychological, and work life domains, can be used to inform the development of a new IT-specific measure of HRQoL in RT patients for use in head-to-head clinical trials or observational studies. Despite limitations associated with the number and the age range of patients recruited, this study suggests that a change in the regimen from twice-daily to once daily among other measures could improve their adherence to IT and their HRQoL by placing less restrictions on their lifestyles.
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Affiliation(s)
| | | | | | | | | | | | - Mondher Toumi
- Public Health (EA 3279), Faculty of Medicine, Aix-Marseille University, Marseille, France
- Correspondence: Mondher Toumi, Public Health (EA 3279), Faculty of Medicine, Aix-Marseille University, 27 bd Jean Moulin, 13385 Marseille Cedex 05, France, Tel/Fax +33 4 9139 6500, Email
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