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Mols RE, Bakos I, Løgstrup BB, Horváth-Puhó E, Gustafsson F, Eiskjær H. Adherence to Pharmacotherapies After Heart Transplantation in Relation to Multimorbidity and Socioeconomic Position: A Nationwide Register-Based Study. Transpl Int 2023; 36:11676. [PMID: 37885807 PMCID: PMC10599149 DOI: 10.3389/ti.2023.11676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023]
Abstract
No studies have examined the impact of multimorbidity and socioeconomic position (SEP) on adherence to the pharmacological therapies following heart transplantation (HTx). Using nationwide Danish registers, we tested the hypothesis that multimorbidity and SEP affect treatment patterns and adherence to pharmacological therapies in first-time HTx recipients. Pharmacological management included cost-free immunosuppressants and adjuvant medical treatment (preventive and hypertensive pharmacotherapies; loop diuretics). We enrolled 512 recipients. The median (IQR) age was 51 years (38-58 years) and 393 recipients (77%) were males. In recipients with at least two chronic diseases, prevalence of treatment with antihypertensive pharmacotherapies and loop diuretics was higher. The overall prevalence of adherence to treatment with tacrolimus or mycophenolate mofetil was at least 80%. Prevalence of adherence to preventive pharmacotherapies ranged between 65% and 95% and between 66% and 88% for antihypertensive pharmacotherapies and loop diuretics, respectively. In socioeconomically disadvantaged recipients, both the number of recipients treated with and adherence to cost-free everolimus, lipid modifying agents, angiotensin-converting enzyme/angiotensin II inhibitors, calcium channel blockers, and loop diuretics were lower. In recipients with multimorbidity, prevalence of treatment with antihypertensive pharmacotherapies and loop diuretics was higher. Among socioeconomically disadvantaged recipients, both number of patients treated with and adherence to cost-free everolimus and adjuvant pharmacotherapies were lower.
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Affiliation(s)
- Rikke E. Mols
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - István Bakos
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Brian B Løgstrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Finn Gustafsson
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Does an eHealth Intervention Reduce Complications and Healthcare Resources? A mHeart Single-Center Randomized-Controlled Trial. J Cardiovasc Dev Dis 2023; 10:jcdd10020077. [PMID: 36826572 PMCID: PMC9960237 DOI: 10.3390/jcdd10020077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/24/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
(1) Background: In the mHeart trial, we showed that an eHealth intervention, mHeart, improved heart transplant (HTx) recipients' adherence to immunosuppressive therapy compared with the standard of care. Herein, we present the analysis assessing whether mHeart reduces complication frequency and healthcare resource use, and whether this reduction depends on patients' adherence. (2) Methods: The mHeart was a single-center randomized-controlled trial (IIBSP-MHE-2014-55) in 134 adult HTx recipients (n = 71 intervention; n = 63 controls). The endpoints were mortality, complications, and resource use during follow-up (mean 1.6 ± 0.6 years). (3) Results: A significantly lower proportion of HTx recipients in mHeart had echocardiographic alteration (2.8% vs. 13.8%; p = 0.02), cardiovascular events (0.35% vs. 2.4%; p = 0.006), infections (17.2% vs. 56%; p = 0.03), and uncontrolled Hba1c (40.8% vs. 59.6%; p = 0.03) than controls. In addition, a significantly lower proportion of patients in the intervention needed hospital (32.4% vs. 56.9%; p = 0.004) or urgent admissions (16.9% vs. 41.4%; p = 0.002) and emergency room visits (50.7% vs. 69.0%; p = 0.03). Adherence status (measured by the self-reported SMAQ) influenced only controls regarding hospitalizations and emergency room visits. Differences were not significant on deaths (intervention 4.2% vs. control 9.5%; p = 0.4) (4) Conclusions: the mHeart strategy significantly reduced the occurrence of the studied post-transplant complications and the need for medical attention in HTx recipients. Adherence status influenced controls in their need for medical care.
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Balakrishnan A, Bailey S, Mroczek D, Serper M, Ladner D, Wolf M. Describing Predictors Of Regimen Nonadherence Among Kidney Recipients Using Multiple Measures. Prog Transplant 2022; 32:226-232. [PMID: 35686344 DOI: 10.1177/15269248221107041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Many kidney recipients struggle with medication adherence and are at greater risk for adverse post-transplant outcomes. Historically, research has focused on single immunosuppressants alone, though all medications within a prescribed regimen are essential for positive outcomes. Research question: Explore predictors of medication regimen nonadherence among a diverse sample of adult kidney recipients by using multiple measures of adherence. Design: A cross-sectional analysis was performed using data from an ongoing clinical trial that enrolled 234 kidney recipients from a large transplant center. We used linear and logit regression models to examine associations of demographic characteristics, social determinants of health, and clinical characteristics with (a) self-reported regimen adherence, measured by the Adherence Starts with Knowledge 12 scale, and (b) immunosuppressant adherence, captured by calculated risk score based on Tacrolimus measurements. Results: Kidney recipients with limited health literacy, overall poorer health, and higher levels of depression demonstrated significantly poorer regimen adherence. Recipients who had dual public/private insurance, took a greater number of medications, and had shorter time since transplant demonstrated significantly poorer immunosuppressant adherence. Conclusion: Social determinants (health literacy and insurance status), and clinical characteristics (overall health status, depression, number of medications, and time since transplant) played significant roles in regimen and immunosuppressant adherence among kidney recipients in our sample. Self-reported adherence, particularly in relation to full medication regimens, can highlight modifiable barriers that might otherwise be overlooked by focusing on adherence to a single immunosuppressant. Depression and health literacy can be assessed and addressed to improve adherence among adult kidney recipients.
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Affiliation(s)
| | - Stacy Bailey
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,370797Institute for Public Health and Medicine - Center for Applied Health Research on Aging, Northwestern University, Chicago, IL, USA
| | - Daniel Mroczek
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,166948Weinberg College of Arts and Sciences, Northwestern University, Chicago, IL, USA
| | - Marina Serper
- 14640University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniela Ladner
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,12244Northwestern Feinberg Comprehensive Transplant Center, Chicago, IL, USA
| | - Michael Wolf
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,370797Institute for Public Health and Medicine - Center for Applied Health Research on Aging, Northwestern University, Chicago, IL, USA
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Mahmoudi R, Moitie T, Dorent R, Guillemin F, Couchoud C. Implementation of patient‐reported outcome measures in a heart transplant recipient registry: first step toward a patient‐centered approach. Clin Transplant 2022; 36:e14708. [DOI: 10.1111/ctr.14708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Redouane Mahmoudi
- Direction médicale et scientifique Agence de la biomédecine Saint Denis La Plaine France
| | - Tiphaine Moitie
- Direction médicale et scientifique Agence de la biomédecine Saint Denis La Plaine France
| | - Richard Dorent
- Direction médicale et scientifique Agence de la biomédecine Saint Denis La Plaine France
- Département de cardiologie Hôpital Bichat – Claude‐Bernard Assistance Publique Hôpitaux de Paris Paris France
| | | | - Cécile Couchoud
- Direction médicale et scientifique Agence de la biomédecine Saint Denis La Plaine France
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Hussain T, Nassetta K, O'Dwyer LC, Wilcox JE, Badawy SM. Adherence to immunosuppression in adult heart transplant recipients: A systematic review. Transplant Rev (Orlando) 2021; 35:100651. [PMID: 34592641 DOI: 10.1016/j.trre.2021.100651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/24/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Successful maintenance of a heart transplant (HTx) graft requires adherence to a triple-drug regimen of immunosuppression. However, achieving adequate adherence can be difficult secondary to complicated dosing regimens, side effects, and mental/emotional barriers. A detailed review of current patterns of adherence to immunosuppression in adult HTx recipients is lacking. OBJECTIVE This systematic review aims to detail the current landscape of adherence to immunosuppression in adult heart transplant patients, including the measurement of adherence, correlates to adherence, health outcomes associated with nonadherence, as well as strategies to improve adherence in HTx patients. METHODS We conducted searches in PubMed MEDLINE, Embase, CENTRAL register of Controlled Trials (Wiley), and Scopus, from inception to March 2020. Studies were eligible if they outlined an aspect of adherence (as noted above in the objective) to immunosuppression in adult HTx patients. The HTx cohort had to contain at least 10 patients and measurement of adherence had to be done with an objective or otherwise validated measure of adherence (e.g. drug levels, automated pill bottles or adherence questionnaires). Two authors independently screened the articles for inclusion, then subsequently reviewed the full texts of the included articles. Data was extracted into standardized forms and bias evaluations were done using the Newcastle-Ottawa or modified Newcastle-Ottawa tools, depending on the study type. The authors followed all guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS The titles/abstracts of 880 articles were reviewed. Ultimately, 23 articles were included in the final review. The median number of participants was 101, with a range of 19 to 1397. Studies provided information on baseline levels of adherence (17 studies), correlates to adherence (14 studies), health outcomes related to nonadherence (3 studies) and interventions to improve adherence (3 studies). Baseline adherence estimates varied greatly depending on the adherence measure. Multiple significant correlates to nonadherence exist and appear to affect patients with certain sociodemographic backgrounds, those with psychological/psychiatric comorbidities and those with poor support structures. Nonadherence is associated with transplant coronary artery disease and acute late rejection; it may also be associated with long-term mortality. Finally, a simplified dosing regimen with once-a-day tacrolimus as well as use of a mobile phone-based intervention were associated with improved adherence. Bias scores were most deficient due to self-reported outcomes in 18 studies, and lack of controls/adjustments for confounders, in 7 studies. CONCLUSIONS Adherence to immunosuppression in transplant patients varies, but is associated with observable and modifiable factors which are worth addressing. Further high-quality studies regarding strategies to improve adherence are needed in the literature.
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Affiliation(s)
- Tasmeen Hussain
- Department of Internal Medicine, Northwestern University McGaw Medical Center, 251 E. Huron St., Ste. 16-738, Chicago, IL 60611, USA.
| | - Keira Nassetta
- Department of Pediatrics, Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL 60611, USA.
| | - Linda C O'Dwyer
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, 320 E. Superior Street, Chicago, IL 60611, USA.
| | - Jane E Wilcox
- Department of Cardiology, Northwestern Memorial Hospital, NMH/Arkes Family Pavilion, Ste. 600; 676 N. St. Clair Ave., Chicago, IL 60611, USA.
| | - Sherif M Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL 60611, USA.
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Shi YX, Liu CX, Liu F, Zhang HM, Yu MM, Jin YH, Shang SM, Fu YX. Efficacy of Adherence-Enhancing Interventions for Immunosuppressive Therapy in Solid Organ Transplant Recipients: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials. Front Pharmacol 2020; 11:578887. [PMID: 33192520 PMCID: PMC7606769 DOI: 10.3389/fphar.2020.578887] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/07/2020] [Indexed: 01/06/2023] Open
Abstract
Background Immunosuppressant non-adherence is a widespread problem among solid organ recipients. With the newly published clinical trials, the randomized controlled trials (RCTs) based systematic review of adherence-enhancing interventions on immunosuppressant adherence in solid organ recipients has not been completed. In this systematic review and meta-analysis, we compared the efficacy of adherence-enhancing interventions versus routine intervention, as performed with RCTs, on immunosuppressant adherence in solid organ transplantation recipients. Methods PubMed, Embase, Cochrane Library, CINAHL full text, and PsycINFO were searched from database inception to December 2019. This review was conducted following the PRISMA’s reporting guidelines and according to the principles recommended by Cochrane Handbook for Systematic Review. Results The search yielded 10,479 articles. A total of 27 articles (26 studies) with 715 participants were included in our analysis. Results from the meta-analysis revealed that as compared with that of the routine intervention group, the rates of overall adherence, dosing adherence, and timing adherence were significantly increased within the adherence-enhancing intervention group, with the pooled risk ratio (RR) of overall adherence = 1.17, [95% confidence interval (CI): 1.07 to 1.28; p = 0.0006]; RR of dosing adherence = 1.21 (95% CI: 1.08 to 1.36, p = 0.001); RR of timing adherence = 1.16 (95% CI: 1.03 to 1.29, p = 0.01). There was a significantly increased adherence score in the adherence-enhancing intervention group; however, no statistical significance on the immunosuppressant blood concentration was found between the two study groups. Results obtained from a subgroup analysis shown interventions led by a multidisciplinary team, both the assessment time at 6 months and 12 months demonstrated a significantly increased adherence rate in the intervention group compared with the control group. Conclusions The findings of this report indicate that clinicians (doctors and nurses) should maintain a long-term intervention protocol to ensure immunosuppressant adherence within solid organ transplant recipients. To accomplish this goal, we recommend a multidisciplinary team-led, comprehensive intervention approach combined with mobile health monitoring for the administration of an effective immunosuppressive therapy regimen.
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Affiliation(s)
- Yue-Xian Shi
- School of Nursing, Peking University, Beijing, China
| | - Chun-Xia Liu
- Department of Urinary Surgery, Peking University Third Hospital, Beijing, China
| | - Fei Liu
- School of Public Health, Peking University, Beijing, China
| | - Hai-Ming Zhang
- Liver Transplantation Center, Clinical Center for Pediatric Liver Transplantation, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Ming-Ming Yu
- School of Nursing, Peking University, Beijing, China
| | - Yin-Hui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, China
| | | | - Ying-Xin Fu
- Department of Kidney Transplantation, Tianjin First Center Hospital, Tianjin, China
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