Assessing barriers to adherence in routine clinical care for pediatric kidney transplant patients

Adherence Rates and Barriers to Second-Generation Antipsychotic Medication Use in Youth with Bipolar Spectrum Disorders Who Have Overweight/Obesity

Objective: Youth with bipolar spectrum disorders (BSD) are frequently prescribed second-generation antipsychotics (SGAs). Nonadherence to treatment often results in increased mood symptoms and diminished quality of life. We examined SGA adherence rates and adherence barriers among youth who have overweight/obesity and are diagnosed with BSD enrolled in a multisite pragmatic clinical trial. Methods: SGA adherence and adherence barriers at baseline via patient- and caregiver report was assessed. Adherence was defined as taking ≥70% of prescribed SGA doses in the past week. The weighted Kappa statistic was used to measure child-caregiver agreement about adherence rates, barriers, and caregiver assistance. Regression analyses were used to examine associations of caregiver assistance, age, sex, race, insurance status, dosing frequency, and number of concomitant medications with adherence. Barriers to adherence were analyzed separately for youth and their caregivers, using logistic regression to assess associations between informant-reported barriers and informant-reported adherence. Results: Participants included 1485 patients and/or caregivers. At baseline, 88.6% of patients self-reported as adherent; 92.0% of caregivers reported their child was adherent. Concordance between patients and caregivers was moderate (k = 0.42). Approximately, 50% of the sample reported no adherence barriers. Frequently endorsed barriers included forgetting, side effects, being embarrassed to take medications, and preferring to do something else. Concordance between informants regarding adherence barriers was weak (k = 0.05-0.36). Patients and caregivers who did not endorse adherence barriers reported higher adherence than those who endorsed barriers. Male sex and having once daily dosing of medications were associated with lower adherence. Discussion: One-week patient- and caregiver-reported adherence was high in this sample. Half of the sample reported adherence barriers. Most commonly endorsed barriers were forgetting, side effects, being embarrassed, and preferring to do something else. Caregivers and patients have unique perspectives regarding adherence barriers. Understanding and addressing treatment barriers in clinical practice may facilitate adherence.

Changes in graft outcomes in recipients <10 kg over 25 years of pediatric kidney transplantation in the United States

BACKGROUND

Kidney transplant (KT) was initially associated with poor outcomes, especially in smaller recipients. However, pediatric transplantation has evolved considerably over time. We investigated the impact of weight at the time of transplant and whether outcomes changed over 25 years for <10 kg recipients.

METHODS

Using the UNOS database, pediatric recipient outcomes were analyzed between 1/1/99 and 12/31/14. KT weight was stratified: <8.6 kg (mean weight of recipients <10 kg), 8.6-9.9 kg, 10-14.9 kg, 15-29.9 kg, and ≥30 kg. Outcomes in recipients <10 kg were then compared between 1990-1999 and 2000-2014.

RESULTS

17 314 pediatric KT recipients were included; 518 (3%) had a transplant weight <10 kg. The highest rates of allograft loss and death were in recipients <8.6 kg and ≥30 kg. Recipients <8.6 kg also had higher rates of delayed graft function, rejection, and longer hospital length of stay. In the multivariable Cox regression model, transplant weight was not a predictor of allograft loss. When compared with recipients <8.6 kg, patient survival hazard ratios associated with recipient weight of 10-14.9 kg, 15-29.9 kg, and ≥30 kg were 0.61 (95%CI: 0.4, 1), 0.42 (95%CI: 0.3, 0.7) and 0.32 (95%CI: 0.2, 0.6), respectively. In the later era of transplant, recipients <10 kg had improved outcomes on univariate analysis; however, the era of transplantation was not an independent predictor of allograft loss or patient survival in Cox regression models.

CONCLUSIONS

Outcomes in children weighing 8.6-9.9 kg at the time of KT were similar to higher weight groups and improved over time; however, special precautions should be taken for recipients <8.6 kg at the time of transplant.

Medication adherence in pediatric kidney transplantation: How to build a bridge over troubled water

Adhering to the immunosuppressive regimen remains one of the biggest challenges for children and adolescents after kidney transplantation. The first paper on nonadherence, co-authored by Dr. Fine, appeared in Pubmed over 45 years ago. Since then, many clinicians and researchers tried to better understand nonadherence and are looking for effective ways to support young people in implementing the complex medication regimen in their daily lives. As a tribute to Dr. Fine, we conducted a comprehensive review providing an overview of adherence-enhancing interventions in the field of pediatric kidney transplantation, thereby focusing on strategies that not only are effective but can also be embedded in daily clinical practice successfully and sustainably. This overview is preceded by a discussion about how to find out who is in need of supportive interventions. We will also argue that interventions should already start before pediatric kidney transplantation and discuss how to decide whether or not a young patient with nonadherence-induced graft loss should undergo retransplantation. We hope this comprehensive overview will rekindle the hope that we can finally turn the tide and beat one of pediatric kidney transplantation's main enemies.

Understanding the impact of pediatric kidney transplantation on cognition: A review of the literature

BACKGROUND

Chronic kidney disease (CKD) is a relatively rare childhood disease that is associated with a wide array of medical comorbidities. Roughly half of all pediatric patients acquire CKD due to congenital anomalies of the kidneys and urinary tract, and of those with congenital disease, 50% will progress to end-stage kidney disease (ESKD) necessitating a kidney transplantation. The medical sequelae of advanced CKD/ESKD improve dramatically following successful kidney transplantation; however, the impact of kidney transplantation on neurocognition in children is less clear. It is generally thought that cognition improves following kidney transplantation; however, our knowledge on this topic is limited by the sparsity of high-quality data in the context of the relative rarity of pediatric CKD/ESKD.

METHOD

We conducted a narrative review to gauge the scope of the literature, using the PubMed database and the following keywords: cognition, kidney, brain, pediatric, neurocognition, intelligence, executive function, transplant, immunosuppression, and neuroimaging.

RESULTS

There are few published longitudinal studies, and existing work often includes wide heterogeneity in age at transplant, variable dialysis exposure/duration prior to transplant, and unaccounted cofounders which persist following transplantation, including socio-economic status. Furthermore, the impact of long-term maintenance immunosuppression on the brain and cognitive function of pediatric kidney transplant (KT) recipients remains unknown.

CONCLUSION

In this educational review, we highlight what is known on the topic of neurocognition and neuroimaging in the pediatric KT population.

The Barriers Assessment Tool-A Patient-Centered Measure of Adherence Barriers in Pediatric Kidney Transplantation

OBJECTIVE

Assessing barriers to adherence provides helpful information to clinicians. The objective of this study was to describe the clinical utility of the Barriers Assessment Tool (BAT) using clinical data for a large, midwestern U.S. pediatric kidney transplant program.

METHODS

Focus group and clinical data were obtained during post-transplant medical visits. Qualitative and quantitative assessment methods were utilized to describe patient and caregiver feedback on the BAT, clinical utility, concordance between reporters, and the effect of interventions on subsequent assessment and electronically measured adherence.

RESULTS

Patients were willing to discuss adherence issues with their care team. There was substantial agreement between patients and caregivers at two timepoints. If a barrier was not addressed, 89.6% (43/48) of patients and 85.9% (67/78) of caregivers reported the same BAT scores from the first to second assessment. When barriers were addressed with a clinic-based intervention, 82% of caregivers reported no adherence barriers. No significant change was found for patient-reported barriers.

CONCLUSIONS

Standardized assessment of barriers to medication adherence provides actionable information to clinicians. Standardized assessment of adherence barriers may give clinicians opportunities to help patients and caregivers overcome these barriers which can decrease risk of rejection.

The learning health system for pediatric nephrology: building better systems to improve health

Learning health systems (LHS) align science, informatics, incentives, and culture for continuous improvement and innovation. In this organizational system, best practices are seamlessly embedded in the delivery process, and new knowledge is captured as an integral byproduct of the care delivery experience aimed to transform clinical practice and improve patient outcomes. The objective of this review is to describe how building better health systems that integrate clinical care, improvement, and research as part of an LHS can improve care within pediatric nephrology. This review will provide real-world examples of how this system can be established in a single center and across multiple centers as learning health networks.

Diversity, Equity, and Inclusion within Pediatric Adherence Science

Given the long-standing history of systemic racism in psychological science, diversity, equity, and inclusion (DEI) efforts are increasingly vital to the advancement and improvement of the field. This commentary extends the seminal work of the article Upending Racism in Psychological Science: Strategies to Change How Our Science is Conducted, Reported, Reviewed, and Disseminated (Buchanan et al., Am Psychol, https://doi.org/10.31234/osf.io/6nk4x , 2020) by providing tangible applications and recommendations to improve DEI integration into pediatric adherence science. Real-world adherence examples are discussed regarding the challenges faced in systematically integrating DEI principles, potential solutions to overcoming barriers, and the implications of these efforts on scientific advancement in an effort to address and dismantle research practices that perpetuate inequity and White supremacy. Specifically, we provide discourse and practical guidance related to the conduct, reporting, reviewing, and dissemination of pediatric adherence science to promote dialog and produce actionable change toward the promotion of health equity and social justice.

My Kidney Identity: Contextualizing pediatric patients and their families kidney transplant journeys

BACKGROUND

Even though having a kidney transplant is the treatment of choice for children with kidney failure, it can cause anxiety for patients and their families resulting in decreased psychosocial functioning, adherence, and self-management. We set out to identify the information needs required to help pediatric patients and their families contextualize their posttransplant experiences as they recalibrate their understanding of normalcy throughout their transplant journey.

METHODS

Participants submitted photographs related to feeling: (1) worried, (2) confident, (3) similar to peers without kidney disease, and (4) different from these peers. The photographs served as a foundation for an in-depth interview.

RESULTS

Nineteen individuals (10 pediatric transplant recipients and 9 caregivers) were interviewed at a mean of 8 years posttransplant. We identified five specific themes and tensions our participants associated with recalibrating their version of "normal" throughout the transplant journey: (1) exchanging information (information consumers vs. information contributors, (2) transitional management (family management vs. self-management), (3) building confidence (worry vs. confidence), (4) telling one's story (hiding vs. self-expression), and (5) normalizing kidney transplantation (feeling different vs. feeling similar). These five themes/tensions form one's Kidney Identity, shift from negative to positive throughout the transplant journey, illustrating a more abstract and complex account of kidney transplantation over time.

CONCLUSIONS

Having a patient view their Kidney Identity over time may support self-reflection of one's progress posttransplant and potentially help clinicians, patients, and their caregivers identify barriers and areas where they may need more support to ensure their successful engagement in their care.

A Cost-effectiveness Analysis of Adherence Promotion Strategies to Improve Rejection Rates in Adolescent Kidney Transplant Recipients

RATIONALE & OBJECTIVE

Nonadherence to medical regimens increases the risk of graft loss among adolescent and young adult recipients of kidney transplants. Interventions that improve adherence may decrease rejection rates, but their perceived costs are a barrier to clinical implementation. We developed a model to assess the cost-effectiveness of an adherence promotion strategy, the Medication Adherence Promotion System (MAPS).

STUDY DESIGN

Simulation-based. Data sources included published articles indexed in Medline or referenced in bibliographies of relevant English-language articles. Data on costs and outcomes were taken from a single clinical center.

SETTING & POPULATION

US adolescent patients after their first kidney transplant.

INTERVENTION

Usual posttransplant care versus usual care plus MAPS.

OUTCOME

Effectiveness measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars.

MODEL, PERSPECTIVE, & TIMEFRAME

Markov state transition decision model. We used a health care system perspective with a lifelong time horizon.

RESULTS

In the base-case analysis, MAPS was more effective and less costly than usual care. MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Extending results to a program level with 100 patients, any adherence promotion intervention similar in effectiveness to MAPS would cost less than $50,000/QALY if the start-up costs were <$2.5 million and annual costs <$188,000. Strategies with costs similar to MAPS that reduce the risk of rejection by as little as 3% would also have similar cost-effectiveness.

LIMITATIONS

Estimates of components and costs for MAPS were based on a single center.

CONCLUSIONS

Adherence promotion strategies with costs similar to MAPS can be cost-effective as long as they reduce rejection rates by at least 3%. This model can be applied to study the cost-effectiveness of adherence promotion strategies with varying costs and outcomes.

Impact of Perceived Barriers on Patient Engagement and Attitudes towards Transition and Transfer

Objective: This study is a preliminary evaluation of how perceived barriers towards transition might impact patient attitudes towards their own readiness and ability to transition, self-efficacy towards their IBD, and the allocation of treatment responsibility. Methods: A sample of 81 young adults with IBD were seen for standard care in a Young Adult Clinic (YAC). Patients completed questionnaires on perceived transition barriers; perceived confidence, importance, motivation, and readiness towards transition and transfer; IBD self-efficacy; and allocation of treatment responsibility. Path model analyses were conducted. Results: Not knowing how and who to transfer to and not understanding insurance details were the most commonly endorsed perceived barriers to transition. A significant relationship was found between the attitude toward transition and allocation of treatment responsibility, but no meaningful indirect effects were found from perceived barriers to the allocation of treatment responsibility, using attitudes toward transition as an intervening variable. The relationship between perceived barriers and allocation of treatment responsibility was at least partially explained by examining the intervening effects of attitudes toward transfer and self-efficacy. Conclusions: The study findings carry important implications for targets of clinical intervention to assist young adults with IBD in engaging in their health care and ultimately transferring into adult care.

Results of an international survey on adherence with anticoagulation in children, adolescents, and young adults: Communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis

BACKGROUND

The ISTH Scientific and Standardization Committee (SSC) Subcommittee on Pediatric/Neonatal Thrombosis and Hemostasis convened a working group on medication adherence to begin to understand the current state of clinical practice to inform priority areas for efforts to improve adherence for children, and adolescents and young adults (AYA) prescribed anticoagulants.

OBJECTIVES

We sought to survey an international group of clinicians involved in anticoagulation management in children and/or AYA about perceptions of medication on health outcomes, clinical practice related to medication adherence, and barriers to assessing and improving medication adherence.

METHODS

Clinicians involved in anticoagulation management in children and/or AYA were surveyed via REDCap® . Descriptive statistics were used to summarize demographic and clinical characteristics and responses to multiple choice and Likert-type questions. Free-text answers were coded based on the Behaviour Change Technique Taxonomy and the Expert Recommendations for Implement Change project.

RESULTS AND CONCLUSIONS

There were 200 participants, 90% of whom were pediatric hematology/oncology physicians. Based on the results, which demonstrate that clinicians are concerned about impact of poor medication adherence and have limited resources to identify and improve adherence, the working group has identified next steps to further understand impact of medication adherence on anticoagulation-related health outcomes, address the need for validated measures to assess medication adherence for all anticoagulants prescribed to this population, and develop an intervention and implementation research agenda to improve outcomes.

A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study

RATIONALE AND OBJECTIVE

Adolescent and young adult kidney transplant recipients have high risk of rejection related to suboptimal adherence. Multi-component interventions improve adherence in controlled trials, but clinical implementation is lacking. We describe an initiative to reduce allograft rejection using evidence-based adherence promotion clinical strategies.

STUDY DESIGN

Interrupted time series.

SETTING AND PARTICIPANTS

Kidney transplant recipients cared for at Cincinnati Children's Hospital ≥1 year post-transplant and taking ≥1 immunosuppressive medication from 2014 through 2017.

QUALITY IMPROVEMENT ACTIVITIES

The following interventions were implemented over 14 months: 1) adherence promotion training for clinical staff, 2) EHR-supported adherence risk screening, 3) systematic assessment of medication adherence barriers, 4) designation of specific staff to address adherence barriers, 5) shared decision-making with the patients to overcome adherence barriers, 6) follow-up to assess progress, 7) optional electronic medication monitoring.

OUTCOMES

Primary Outcome: Late acute rejection. Process measures: barriers assessments performed, barriers identified, number of interventions performed. Secondary outcomes/balancing measures: de novo DSA, biopsy rate, rejections per biopsy.

ANALYTICAL APPROACH

Time series analysis using statistical process control, evaluated patient-days between acute rejections as well as monthly rejections per 100 patient-months before and after implementation. To control for known rejection risk factors including changes in treatment and case mix, multivariable analyses were performed.

RESULTS

The monthly rejection rate fell from 1.61 rejections/100 patient-months in the 26-months pre-implementation to 0.88 rejections/100 patient-months in the 22-months post-implementation. In multivariable analysis, MAPS was associated with a 50% reduction in rejection incidence (IRR 0.50, 95% CI: 0.27-0.91, p=0.02). DSA and time since transplant were also associated with rejection incidence (IRR 2.27, p=0.02 and IRR 0.87, p=0.02, respectively) LIMITATIONS: A single center study. Potential confounding by unmeasured variables.

CONCLUSIONS

Clinical implementation of evidence-based adherence-promotion strategies was associated with a 50% reduction in acute rejection incidence over two years.

Predicting acute rejection in children, adolescents, and young adults with a kidney transplant by assessing barriers to taking medication

BACKGROUND

Nonadherence to immunosuppression is common among pediatric, adolescent, and young adult kidney transplant recipients and a leading cause of graft loss. Assessing barriers to medication adherence in clinical practice may identify patients at risk for rejection and provide therapeutic targets.

METHODS

Kidney transplant patients and/or their caregivers were assessed for 14 barriers to medication adherence using the barriers assessment tool. We compared rejection rates between patients with at least one reported adherence barrier to those without reported adherence barriers using a Kaplan-Meier estimator and Cox proportional hazard models to adjust for other mediators of acute rejection at 2 years following barriers assessment.

RESULTS

Ninety-eight patients were assessed for barriers to adherence. Over the 2-year observation period, 22 patients developed biopsy-proven acute rejection (BPAR). Kaplan-Meier estimates show that patients with an identified barrier to adherence were more likely to have BPAR (p = 0.02) than patients without an identified barrier in the 24 months following barriers assessment. The median time to rejection for patients who experienced acute rejection was 175.5 days (IQR 63-276 days) from the time of barriers assessment. An identified barrier to adherence remained the only statistically significant predictor of BPAR with Cox modeling (HR 2.6, p = 0.04), after accounting for age, sex, and race.

CONCLUSIONS

Pediatric and adolescent kidney transplant recipients with identified adherence barriers are at increased risk for acute rejection. Barriers to adherence provide a potentially modifiable therapeutic target that can be assessed in clinic to guide targeted interventions.

Assessment of medication adherence in children and adults with congenital adrenal hyperplasia and the impact of knowledge and self-management

BACKGROUND

Congenital adrenal hyperplasia (CAH) is caused by a deficiency of one of the enzymes required for cortisol biosynthesis. The disease is classified as either classic (severe phenotype), subdivided into simple virilizing (SV) and salt-wasting (SW), or non-classic (NC) CAH. The treatment regime involves life-long glucocorticoid replacement, especially in classic phenotype.

OBJECTIVES

We aimed to assess medication adherence, endocrine knowledge and self-management in patients with CAH and to compare patients' and physicians' assessments of medication adherence.

METHODS

A prospective cross-sectional study of 108 patients with CAH (52 children and 56 adults) and 45 parents/caregivers. Two adherence measures were used, a self-reported questionnaire named Adherence Starts with Knowledge (ASK-12) with a cut-off level > 22 defined as poor adherence rate, and an assessment by a physician based on growth rate, 17-hydroxyprogesterone profile, and medical history, ranked using a five-point Likert scale. Measurements of the patients'/parents' knowledge and self-management were performed using Endocrine Society Clinical Practice Guidelines.

RESULTS

Self-reported medication adherence was good with 74% of the participants reported good adherence with higher adherence in patients with the SW form. The highest endocrine knowledge and self-management were found in parents compared with children and adults with classic CAH. There was 30% discordance between the assessments by a physician and the self-reported ASK-12 scores independent of the severity of CAH.

CONCLUSION

Patients and endocrinologists reported high medication adherence, however, discordance was found in 30% of the studied patients. Patients with the more severe form of CAH had higher adherence rates and demonstrated good endocrine knowledge/self-management.

Reflecting on patient-generated photographs of the pediatric renal transplant experience

BACKGROUND AND OBJECTIVES

Poor self-management contributes to reduced renal allograft survival during adolescence and young adulthood. Providing patients with self-reflection tools to help explore the question "Is my experience normal?" may help mitigate these challenges. We explore Photograph-elicitation, a qualitative method where images are used to prompt individuals to talk about their personal experiences and values, engages pediatric transplant recipients and their families to generate insight into their experiences and the challenges they face after transplant.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

Pediatric renal transplant recipients and one family member from Seattle Children's Hospital submitted 5 photographs showcasing their transplant story, which were used as prompts during semi-structured interviews. Interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Twenty-four individuals (13 patients: ages 7-21, and 11 parents) completed the study. Conversations generated by the photographs covered topics in more depth than a routine clinical encounter leading to more opportunities for reflection by patients and their family. The photographs generated conversations on four emergent themes: (a) sensemaking; (b) transitions and agency; (c) social interactions and community engagement; and (d) barriers and obstacles.

CONCLUSIONS

Photograph elicitation generated a rich dataset describing a range of pediatric renal transplant experiences helping physicians gain a rich and nuanced understanding of the daily lives and experiences of their patients outside the clinical setting. Photograph elicitation, as a clinical intervention, may provide new opportunities to address previously unrecognized modifiable risk factors, improving graft survival and health-related quality of life.

Empowering patients to adhere to their treatment regimens: A multifaceted approach

It is well-recognized that adolescence and early adulthood are a high-risk period for non-adherence with treatment regimens in solid organ transplant recipients, leading to high rates of rejection and graft loss (Transplantation, 92, 2011, 1237; Pediatr Transplant, 9, 2005, 381; Transplantation, 77, 2004, 769). Preventing medication non-adherence is the holy grail of transplant adolescent care. If we can determine how best to support our patients in taking their daily medications as prescribed, we can improve long-term health, reduce need for re-transplantation, and reduce healthcare costs. In the last few years, several studies have provided us with additional insights into potentially effective interventions and have highlighted existing gaps in knowledge. This article reviews recent literature published over the last 5 years on the topic of adherence in transplant recipients, highlighting insights and opportunities to promote adherence at the individual patient level, family level, healthcare system level, and community level. Above all, the recent work that is highlighted suggests that adherence interventions for prevention and treatment must be multifaceted, individualized, and longitudinal to be effective.

Implementing a Process to Systematically Identify and Address Poor Medication Adherence in Pediatric Liver Transplant Recipients

Objectives

Poor adherence to medication following pediatric liver transplantation remains a major challenge, with some estimates suggesting that 50% of adolescent liver transplant recipients exhibit reduced medication adherence. To date, no gold standard has emerged to address this challenge; however, system interventions are most likely to be successful. We sought to implement a system to identify and address adherence barriers in a liver transplant clinic.

Methods

Using structured quality improvement methods, including multiple plan-do-study-act cycles, we developed a system to screen for patients at risk of poor adherence, identify patient- and/or parent-reported barriers to adherence, and partner with patients to overcome identified barriers. We developed a process to track key outcomes, including the variability in tacrolimus trough levels and episodes of late acute cellular rejection.

Results

The practice saw a total of 85 patients over 6 months, and about half were females. Over this period, the improvement team implemented this system-level process with high reliability (>90% of patients received the bundle of interventions). The most commonly identified adherence barrier by patients and caregivers was "forgetting." The second most commonly identified adherence barrier by patients was that the medication "gets in the way of their activities," whereas by caregivers, it was "difficulty swallowing pills."

Discussion

We identified challenges and opportunities to screen for poor adherence and identify patient- and/or caregiver-reported barriers to immunosuppression adherence. Identifying such barriers and partnering with patients to overcome those barriers using patient-centered, barrier-specific interventions could improve long-term graft survival through improved medication adherence.

Effect and features of information technology-based interventions on self-management in adolescent and young adult kidney transplant recipients: a systematic review

Introduction

Adolescent and young adult periods are characterized by increased risk-taking, impulsive behavior, and nonadherence issues, which makes it equally challenging for patients and their health care professionals. Health information technology (IT) has the potential to empower patients.

Objective

Determine the effects and features of IT-based interventions for self-management of adolescents and young adults in kidney transplant recipients.

Materials and Methods

A comprehensive survey was done on Medline and Scopus in September 2018. Eligible studies included randomized controlled trials (RCTs) and quasi-experimental studies focused on automated IT-based interventions. Studies contained information about adolescent and young adult kidney transplant recipients aged under 25, all published in English. The articles were combined with each other based on the classification of outcomes, the type of interventions, and their impact. The studies were categorized based on the impact of interventions as positive and statistically significant, with no effect, or a combined effect (both positive significance and without effect).

Results

In this review, of a total of 2,242 retrieved articles, collected from Scopus and PubMed databases, 5 studies met the full-text inclusion criteria. Interventions were performed using computerized systems (3 studies), smartphone application/personal digital ass (PDA) (1 study), and multiple components (1 study). These studies evaluated 15 outcomes, including 7 care process and 8 clinical outcomes. In 6 of 15 outcomes (40%), interventions had a statistically significant positive effect.

Conclusion

IT-based interventions such as mobile health/personal digital assistant(PDA), computer systems and multi-component have the potential to improve self-management in adolescents and young adult kidney transplant recipients (care process outcomes). It is recommended to conduct complementary research to examine the effect of IT-based self-management interventions on clinical outcomes in kidney transplant recipients.

Providers' Perspectives on Adherence to Hormonal Therapy in Breast Cancer Survivors. Is there a Role for the Digital Health Feedback System?

Objective

Despite the benefits of hormonal therapy (HT) adherence remains suboptimal in ER positive breast cancer patients. Medication adherence is challenging to assess and tends to be overestimated. The Digital Health Feedback System (DHFS) consists of an ingestible sensor attached to a pill that sends intake date and time to a smart phone or computer. Patients can share this information with health care providers and other persons. The DHFS can also send reminders. This mixed methods study examined providers' perceptions of HT medication adherence. The potential role of the DHFS in enhancing medication tracking and adherence was also explored.

Methods

We conducted semi-structured interviews with key informants (N=10). Questions examined perceptions about adherence barriers and facilitators, challenges tracking adherence, and views on the DHFS. Findings informed the development of a survey that was administered online (N=19).

Results

Providers emphasized the importance of fostering open and trustful communication around adherence. The most mentioned challenges to assessing adherence were the patient not disclosing discontinuation immediately (78.9%) and over-reporting adherence (57.9%). The perceived potential benefits of DHFS were the ability to track adherence better (94.7%) and reminders to take the medication (68.4%). Safety to ingest a sensor was as a major perceived barrier (8 4.2%).

Conclusion

Interventions that target providers and doctor-patient communication are warranted to enhance adherence and reduce communication delays around HT discontinuation.

Practice Implications

DHFS has the potential to enhance HT adherence by directly targeting barriers. Future studies should also examine the feasibility of adopting the DHFS with cancer patients.

Age-associated decrease in de novo donor-specific antibodies in renal transplant recipients reflects changing humoral immunity

Background

Older age at organ transplantation is associated with increased risk of infection and malignancy but reduced risk of cellular rejection. De novo donor-specific anti-HLA antibodies (dnDSA), are key biomarkers associated with reduced long-term allograft survival, yet there is a lack of data focusing on age-associated changes.

Methods

Development of dnDSA was restrospectively analyzed in all subjects who received a kidney transplant at the University Hospital Zurich between 01/2006 and 02/2015. Follow up continued until 03/2016. The incidence of dnDSA in different age categories was compared with special focus on the extremes of age: children < 10 years (n = 19) and adults ≥60 years of age (n = 110).

Results

Incidence of dnDSA gradually decreased with age, with older recipients having a significantly lower risk (HR 0.21, p = 0.0224) compared to pediatric recipients. Cumulative incidence of dnDSA at 2, 5 and 10 years was 6.2, 9.1 and 36% in the older recipients versus 5.3, 29.5 and 47.1% in pediatric recipients. Median time to development of dnDSA was similar (older 720 days, min 356, max 3646 days; children 1086 days, min 42, max 2474 days). Annual incidence was highest within the first two years after transplantation in the older recipients and peaked in years two to four in pediatric recipients. DnDSA were predominantly class II. More dnDSA were observed with cyclosporine as compared to tacrolimus.

Conclusion

Older kidney transplant recipients have a lower risk of developing dnDSA than pediatric recipients, pointing towards reduced humoral immune reactivity with increasing age. This observation raises the question of adjustment in immunosuppression.

Nonadherence after pediatric renal transplantation: detection and treatment

PURPOSE OF REVIEW

Nonadherence is a problem in adolescents and young adults. Risk factors are classified as those of the individual, family, health-care-system, or community. I present the latest reports and how to tackle nonadherence.

RECENT FINDINGS

Nonadherence risk is independent of one's origin in a high-poverty or low-poverty neighborhood or having private or public insurance in respect to African Americans. Females with male grafts have higher graft-failure risks than do males. Female recipients aged 15-24 with grafts from female donors have higher graft-failure risk than do males. In study of nonadherence risks, such findings must be taken into account. Antibody-mediated rejection is seen in nonadherence. The sirolimus and tacrolimus coefficient of variation is associated with nonadherence, donor-specific antibodies, and rejection. Adolescents had electronically monitored compliance reported by e-mail, text message or visual dose reminders and meetings with coaches. These patients had significantly greater odds of taking medication than did controls. Transition programs have an impact on renal function and rejection episodes.

SUMMARY

Individual risk factors are many, and methods for measuring nonadherence exist. Each transplant center should have a follow-up program to measure nonadherence, especially in adolescence, and a transition program to adult care.

Does a multimethod approach improve identification of medication nonadherence in adolescents with chronic kidney disease?

BACKGROUND

Medical provider assessment of nonadherence is known to be inaccurate. Researchers have suggested using a multimethod assessment approach; however, no study has demonstrated how to integrate different measures to improve accuracy. This study aimed to determine if using additional measures improves the accurate identification of nonadherence beyond provider assessment alone.

METHODS

Eighty-seven adolescents and young adults (AYAs), age 11-19 years, with chronic kidney disease (CKD) [stage 1-5/end-stage renal disease (ESRD)] and prescribed antihypertensive medication, their caregivers, and 17 medical providers participated in the multisite study. Five adherence measures were obtained: provider report, AYA report, caregiver report, electronic medication monitoring (MEMS), and pharmacy refill data [medication possession ratio (MPR)]. Concordance was calculated using kappa statistic. Sensitivity, specificity, positive predictive power, and negative predictive power were calculated using MEMS as the criterion for measuring adherence.

RESULTS

There was poor to fair concordance (kappas = 0.12-0.54), with 35-61% of AYAs classified as nonadherent depending on the measure. While both providers and MEMS classified 35% of the AYAs as nonadherent, sensitivity (0.57) and specificity (0.77) demonstrated poor agreement between the two measures on identifying which AYAs were nonadherent. Combining provider report of nonadherence and MPR < 75% resulted in the highest sensitivity for identifying nonadherence (0.90) and negative predictive power (0.88).

CONCLUSIONS

Nonadherence is prevalent in AYAs with CKD. Providers inaccurately identify nonadherence, leading to missed opportunities to intervene. Our study demonstrates the benefit to utilizing a multimethod approach to identify nonadherence in patients with chronic disease, an essential first step to reduce nonadherence.

Predicting Health Care Utilization and Charges Using a Risk Score for Poor Adherence in Pediatric Kidney Transplant Recipients

Pediatric kidney transplant recipients must follow a complicated regimen of timely adherence to immunosuppressant medication, routine blood work, and medical follow-up visits. Failure to adhere to the recommended regimen can result in medical complications and costly treatment. We developed a novel risk score to identify patients at risk for poor adherence behaviors and evaluated whether it would predict future health care utilization and charges. Our risk stratification score combined three simple pass/fail metrics of adherence derived directly from the electronic health record including standard deviation of immunosuppression drug levels, timely laboratory monitoring, and timely clinic visits as indicated by our clinical protocol. Risk for poor adherence was assessed over a three-month period. Linear regression was used to predict subsequent health care charges and utilization. Greater than 75% of patients had some degree of nonadherence risk during the study period, but there were no significant differences found on any outcomes for the overall score. However, when the individual components of the overall risk score were evaluated independently, patients with tacrolimus drug level standard deviation ≥2 (e.g., a marker of poor adherence) had greater health care utilization (e.g., hospitalizations) and increased total charges. Additionally, patients who did not follow up in clinic at least every 4 months had more ED visits and ED-related charges, but fewer hospitalizations. Regular clinic visits and minimizing drug level variation may deter future costly ED visits and hospitalizations.

Barriers to Adherence in Juvenile Idiopathic Arthritis: A Multicenter Collaborative Experience and Preliminary Results

OBJECTIVE

Nonadherence is currently an underrecognized and potentially modifiable obstacle to care in juvenile idiopathic arthritis (JIA). The purpose of our study was to design and implement a standardized approach to identifying adherence barriers for youth with JIA across 7 pediatric rheumatology clinics through the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) and to assess the frequency of adherence barriers in patients and their caregivers across treatment modalities.

METHODS

An iterative process using coproduction among parents and providers of patients with JIA was used to design the Barriers Assessment Tool to screen for adherence barriers across 4 treatment modalities (i.e., oral medications, injectable medications, infusions, and physical/occupational therapy). This tool was implemented in 7 rheumatology clinics across the United States and patient responses were collected for analysis.

RESULTS

Data were collected from 578 parents and 99 patients (n = 44 parent-child dyads). Seventy-seven percent (n = 444) of caregivers and 70% (n = 69) of patients reported at least 1 adherence barrier across all treatment components. The most commonly reported adherence barriers included worry about future consequences of therapy, pain, forgetting, side effects, and embarrassment related to the therapy. There was no significant difference between endorsement of barriers between parents and adolescents.

CONCLUSION

Implementing a standardized tool assessing adherence barriers in the JIA population across multiple clinical settings is feasible. Systematic screening sheds light on the factors that make adherence difficult in JIA and identifies targets for future adherence interventions in clinical practice.

Adherence to antiepileptic drugs in adolescents with epilepsy

INTRODUCTION

The aims of the current study were to identify patterns and predictors of adherence in adolescents with epilepsy over one year, as well as its impact on seizures and health-related quality of life (HRQOL).

METHODS

Forty-eight adolescents with epilepsy (M_age=14.8+1.5, 69% female, 73% White: NonHispanic) and their caregivers completed questionnaires assessing demographics, epilepsy knowledge, side effects, adherence barriers, family functioning, and HRQOL at quarterly clinic visits over one year. Adherence was monitored electronically via MEMS TrackCaps. Seizures were determined via chart review.

RESULTS

Baseline adherence was 86.05% and significantly decreased over 12months (b=-2.07, p<0.001). Higher adherence was predicted by higher socioeconomic status (SES) (b=0.04, p<0.05), more side effects (b=0.06, p<0.01), fewer caregiver-reported adherence barriers (b=0.18, p<0.05), and lower family conflict (b=-0.19, p<0.05). Change in adherence over 12months did not significantly predict HRQOL or seizures.

CONCLUSIONS

This is the first longitudinal study of objective adherence in adolescents with epilepsy. Given adolescence is a period of vulnerability during development, including declining adherence, caregivers are encouraged to continue collaborating with their adolescents around epilepsy management. Adherence barriers represent an ideal target for intervention and can be implemented in the clinic by frontline providers. Multidisciplinary care can address low SES (social work, financial advocates) and family conflict (psychologists, therapists) in patients with the ultimate goal of optimizing adherence and health outcomes.