Cost-related immunosuppressive medication nonadherence among kidney transplant recipients

Ethical and Policy Issues Arising in Crowdfunding for Solid Organ Transplantation: A Content Analysis of Newspaper Coverage of Recipient and Donor Fundraising Campaigns

BACKGROUND

Solid organ transplantation improves the quality of life for patients but has significant out-of-pocket expenses for donors and recipients in the USA, leading many to utilize crowdfunding for donations to cover expenses. We sought to characterize crowdfunding for transplant patients and to identify ethical and policy issues.

METHODS

We obtained newspaper articles that described crowdfunding campaigns for organ transplant patients from Nexis-Uni. Using Nvivo, we identified and analyzed article details, patient characteristics, features of campaigns, additional fundraisers, and policy and ethical issues related to crowdfunding.

RESULTS

Most sources were published between 2015 and 2020. Of 231 patients identified, 43% were thoracic organ recipients and 42% were kidney recipients. GoFundMe was the most popular platform. 78% of patients reported at least one intended use of crowdfunding; medical expenses were the most cited reason. Ten percent of articles described at least one ethical or policy consideration related to crowdfunding for organ transplant. Concerns included violations of federal laws prohibiting donors from receiving "valuable consideration" for an organ, taxation of funds, loss of Medicaid or disability benefits, accountability for fund usage, and crowdfunding requirements for organ waiting list placement. In several cases, transplants were delayed due to crowdfunding concerns.

CONCLUSIONS

Our findings reveal crowdfunding characteristics and financial barriers present among transplant patients. Furthermore, our study suggests that the ethical and policy implications for crowdfunding in the transplant population are not yet adequately assessed. National regulations and transplant center policies may need to be modified to address issues raised by patient crowdfunding.

Economic Evaluation in Kidney Transplantation: A Scoping Review and Novel PESTLE Stakeholder Gaps Analysis

AIM

The objective of this study was to systematically review the literature related to the economic evaluation of kidney transplantation to determine the extent of current research and identify gaps for future research.

SUBJECT AND METHODS

We searched 4 medical and 2 economic electronic databases as well as hand-searching reference lists of review articles and other pertinent articles. Exclusion criteria included articles that did not include original work (ie, reviews), were not in English, and were not journal articles or economic working papers (eg, commentaries, theses, abstracts). Full-text data abstraction included qualitative and quantitative parameters with the intent to perform a gap analysis for future research.

RESULTS

A total of 299 articles were included and spanned a 48-year period from 1968 to 2016, with >73% published in 2000 or after. The most common topics included immunosuppression drugs, dialysis vs kidney transplantation, organ allocation, and the potential market for donor organs. Most articles were from the United States and originated from 73 medical journals and 34 economic journals or working paper centers. There were 58 articles dealing with costing, 153 using cost-effectiveness, 69 using economic modeling, 6 performing systematic reviews with meta-analyses, and 13 exploring the qualitative financial environment of individuals and the economy.

CONCLUSIONS

Research gaps were identified in every parameter used to evaluate the studies, and a new system of gap analysis for scoping reviews was also proposed.

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

Prevalence and Correlates of Cost-Related Medication Nonadherence to Immunosuppressive Drugs After Heart Transplantation: The International Multicenter Cross-sectional Bright Study

BACKGROUND

Cost-related medication nonadherence (CRMNA) refers to not taking medications as prescribed because of difficulties paying for them.

OBJECTIVES

The aims of this study were (1) to assess the prevalence of CRMNA to immunosuppressants in heart transplant recipients internationally and (2) to determine multilevel correlates (patient, center, and healthcare system levels) of CRMNA.

METHODS

Using data from the cross-sectional international BRIGHT study, applying multistaged sampling, CRMNA was assessed via 3 self-report items in 1365 patients from 36 heart transplant centers in 11 countries. Cost-related medication nonadherence was defined as any positive answer on any of the 3 items. Healthcare system-level (ie, insurance coverage, out-of-pocket expenditures) and patient-level (ie, intention, perceived financial burden, cost as a barrier, a health belief regarding medication benefits, cost-related self-efficacy, and demographic factors) CRMNA correlates were assessed. Correlates were examined using mixed logistic regression analysis.

RESULTS

Across all study countries, CRMNA had an average prevalence of 2.6% (range, 0% [Switzerland/Brazil] to 9.8% [Australia]) and was positively related to being single (odds ratio, 2.29; 95% confidence interval, 1.17-4.47), perceived financial burden (odds ratio, 2.15; 95% confidence interval, 1.55-2.99), and cost as a barrier (odds ratio, 2.60; 95% confidence interval, 1.66-4.07). Four protective factors were identified: white ethnicity (odds ratio, 0.37; 95% confidence interval, 0.19-0.74), intention to adhere (odds ratio, 0.44; 95% confidence interval, 0.31-0.63), self-efficacy (odds ratio, 0.54; 95% confidence interval, 0.43-0.67), and belief about medication benefit (odds ratio, 0.70; 95% confidence interval, 0.57-0.87). Regarding variability, 81.3% was explained at the patient level; 13.8%, at the center level; and 4.8%, at the country level.

CONCLUSION

In heart transplant recipients, the CRMNA prevalence varies across countries but is lower than in other chronically ill populations. Identified patient-level correlates are novel (ie, intention to adhere, cost-related barriers, and cost-related self-efficacy) and indicate patient-perceived medication cost burden.

Quantifying spillover benefits in value assessment: a case study of increased graft survival on the US kidney transplant waitlist

AIM

To quantify the wider impacts of increased graft survival on the size of the kidney transplant waitlist and health and economic outcomes.

MATERIALS AND METHODS

The analysis employed known steady-state solutions to a double-queueing system as well as simulations of this system. Baseline input parameters were sourced from the Organ Procurement and Transplant Network and the United States Renal Data System. Three increased graft survival scenarios were modeled: decreases in repeat transplant candidates joining the waitlist of 25%, 50%, and 100%.

RESULTS

Under the three scenarios, we estimated that the US waitlist size would decrease from 91,822 to 85,461 (6.9% decrease), 80,073 (12.8% decrease), and 69,340 (24.4% decrease), respectively. Patient outcomes improved, with lifetime quality-adjusted life years (QALYs) for a 1-year cohort of transplant recipients increasing by 10,010, 16,888, and 43,345 over the three scenarios. Discounted lifetime costs for the cohort in the new steady state were lower by $1.6 billion, $2.3 billion, and $9.0 billion for each scenario, respectively. Spillover impacts (i.e. benefits that accrued beyond the patients who directly experienced increased graft survival) accounted for 41-48% of the QALY gains and ranged from cost increases of 3.3% to decreases of 5.5%.

LIMITATIONS

The model is a simplification of reality and does not account for the full degree of patient heterogeneity occurring in the real world. Health economic outcomes are extrapolated based on the assumption that the median patient is representative of the overall population.

CONCLUSIONS

Increasing graft survival reduces demand from repeat transplants candidates, allowing additional candidates to receive transplants. These spillover impacts decrease waitlist size and shorten wait times, leading to improvements in graft and patient survival as well as quality-of-life. Cost-effectiveness analyses of treatments that increase kidney graft survival should incorporate spillover benefits that accrue beyond the direct recipient of an intervention.

Immigration status and end-stage kidney disease: Role of policy and access to care

Immigration status is an important mitigating factor in determining the provision of dialysis and kidney-related care. Immigrants make up the largest uninsured group in the country. For immigrants with end-stage kidney disease (ESKD), dialysis access varies by insurance type and by state, leading to great variability in the availability of kidney care. In some states, undocumented immigrants may only qualify for hemodialysis when critically ill (emergency hemodialysis), which is associated with higher mortality, hospital length of stay, and cost, in addition to an emotional burden on patients, their caregivers, and healthcare professionals. Barriers to effective care for immigrants with ESKD include immigration status, insurance access, and availability of pre-end stage kidney disease care, vascular access, and transplant. Effective strategies for improving dialysis care for immigrants include advocacy at the state and federal level, broadening definitions under Emergency Medicaid, and improving benefits for home therapies and transplantation options.

Meeting Regulatory Requirements for Drugs with a Narrow Therapeutic Index: Bioequivalence Studies of Generic Once-Daily Tacrolimus

Despite growing clinical confidence in generics and their potential to reduce long-term healthcare costs, the transplant community have had real concerns about the use of generic immunosuppressants. One such immunosuppressant is tacrolimus, a cornerstone of lifelong treatment for patients who have undergone a solid organ transplant. Tacrolimus has a narrow therapeutic index (NTI), giving rise to questions about the potential for clinically relevant altered drug exposure. Its use in transplant patients also gives rise to questions about the most discriminative subject population for bioequivalence studies. The recognised need for stringent criteria to support approval of generic drugs with an NTI led the European Medicines Association and Health Canada to provide detailed information on requirements for bioequivalence studies and introduce tighter bioequivalence limits for these drugs, including tacrolimus. The aim of this article is to illustrate how regulatory guidance is implemented during the clinical development of generic immunosuppressants, using a generic, once-daily prolonged-release formulation of tacrolimus as an example.

Pandemic-related unemployment impacts transplant in the US

This month’s installment of “The AJT Report” discusses how COVID-19 pandemic-related unemployment is having a uniquely adverse impact on the transplant community in the US. We also report on England’s new—and game-changing—organ donation law.

Hemodialysis care for undocumented immigrants with end-stage renal disease in the United States

PURPOSE OF REVIEW

Across the United States, significant variation exists in the provision of care of undocumented immigrants with end-stage renal disease (ESRD), with some states providing standard dialysis, and other states providing emergency-only hemodialysis (EoHD).

RECENT FINDINGS

EoHD is associated with higher morbidity and mortality compared with standard hemodialysis. EoHD is also associated with higher healthcare utilization, resulting in more emergency department visits, more days spent in the hospital, and higher healthcare costs. Undocumented immigrants with ESRD who rely on EoHD also experience crippling and potentially fatal physical symptoms as well as psychosocial suffering, with some patients describing recurrent near-death experiences. Clinicians who provide EoHD to undocumented patients report experiencing moral distress and symptoms of professional burnout because of providing care that they perceive as unethical and far below the standard of care.

SUMMARY

Undocumented immigrants with ESRD who rely on EoHD have worse health outcomes and quality of life compared with patients who receive standard hemodialysis. EoHD is also more costly to the healthcare system. Healthcare policy reform is critical as more research demonstrates the worse clinical outcomes and higher costs of EoHD.

Economic Evaluation of Extending Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients in the Current Era

BACKGROUND

Kidney transplant recipients must take immunosuppressant drugs to prevent rejection and maintain transplant function. Medicare coverage of immunosuppressant drugs for kidney transplant recipients ceases 36 months after transplantation, potentially increasing the risk of transplant failure. A contemporary economic analysis of extending Medicare coverage for the duration of transplant survival using current costs of immunosuppressant medications in the era of generic equivalents may inform immunosuppressant drug policy.

METHODS

A Markov model was used to determine the incremental cost and effectiveness of extending Medicare coverage for immunosuppressive drugs over the duration of transplant survival, compared with the current policy of 36-month coverage, from the perspective of the Medicare payer. The expected improvement in transplant survival by extending immunosuppressive drug coverage was estimated from a cohort of privately insured transplant recipients who receive lifelong immunosuppressant drug coverage compared with a cohort of Medicare-insured transplant recipients, using multivariable survival analysis.

RESULTS

Extension of immunosuppression Medicare coverage for kidney transplant recipients led to lower costs of -$3077 and 0.37 additional quality-adjusted life years (QALYs) per patient. When the improvement in transplant survival associated with extending immunosuppressant coverage was reduced to 50% of that observed in privately insured patients, the strategy of extending drug coverage had an incremental cost-utility ratio of $51,694 per QALY gained. In a threshold analysis, the extension of immunosuppression coverage was cost-effective at a willingness-to-pay threshold of $100,000, $50,000, and $0 per QALY if it results in a decrease in risk of transplant failure of 5.5%, 7.8%, and 13.3%, respectively.

CONCLUSIONS

Extending immunosuppressive drug coverage under Medicare from the current 36 months to the duration of transplant survival will result in better patient outcomes and cost-savings, and remains cost-effective if only a fraction of anticipated benefit is realized.

The association between loss of Medicare, immunosuppressive medication use, and kidney transplant outcomes

Kidney transplant recipients aged <65 years qualify for Medicare coverage, but coverage ends 3 years posttransplant. We determined the association between timing of Medicare loss and immunosuppressive medication fills and kidney allograft loss. Using data from the Scientific Registry of Transplant Recipients (SRTR), US Renal Data System, and Symphony pharmacy fill database, we analyzed 78 861 Medicare-covered, kidney-alone recipients aged <65 years, and assessed the timing of Medicare loss posttransplant: early (<3 years), on-time (at 3 years), or late (>3 years). Immunosuppressant use was measured as medication possession ratio (MPR). Allograft loss was assessed using SRTR data. MPR was lower for recipients with early or late Medicare loss compared with no coverage loss for all immunosuppressive medication types. For calcineurin inhibitors, early Medicare loss was associated with a 53% to 86% lower MPR. On-time Medicare loss was not associated with a lower MPR. When recipients were matched by age, posttransplant timing of Medicare loss, and donor risk, the hazard of allograft loss was 990% to 1630% higher after early Medicare loss, and 140% to 740% higher after late Medicare loss, with no difference in the hazard for on-time Medicare loss. Ensuring ongoing Medicare access before and after 3 years posttransplant could affect graft survival.

Long-Term Outcomes among Kidney Transplant Recipients and after Graft Failure: A Single-Center Cohort Study in Brazil

Background

The results of kidney transplantation are impacted by the categories of events responsible for patient death and graft failure. The objective of this study was to evaluate the causes of death and graft failure and outcomes after graft failure among kidney transplant recipients.

Methodology

A retrospective cohort study was conducted with 944 patients who underwent kidney transplantation. Outcomes were categorized in a managed and hierarchical manner.

Results

The crude mortality rate was 10.8% (n=102): in 35.3% cause of death was infection, in 30.4% cardiovascular disease, and in 15.7% neoplasia and in 6.8%, it was not possible to determine the cause of death. The rate of graft loss was 10.6%. The main causes of graft failure were chronic rejection (40%), acute rejection (18.3%), thrombosis (17.3%), and recurrence of primary disease (16.5%). Failures due to an acute rejection occurred earlier than those due to chronic rejection and recurrence (p<0.0001). As late causes of graft loss, death with the functioning kidney occurred earlier than recurrence and chronic rejection (p=0.008). The outcomes after graft failure were retransplantation in 26.1% and death in 21.4%, at a mean of 25.5 and 21.4 months, respectively.

Conclusion

It was possible to identify more than 90% of the events responsible for the deaths of transplanted patients, predominantly infectious and cardiovascular diseases. Among the causes of graft failure, chronic and acute rejections and recurrence were the main causes of graft failure which were followed more frequently by retransplantation than by death on dialysis.

Secular Trends in the Cost of Immunosuppressants after Solid Organ Transplantation in the United States

BACKGROUND AND OBJECTIVES

Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period.

RESULTS

Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%).

CONCLUSIONS

The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.

Racial disparity in kidney transplant survival relates to late rejection and is independent of steroid withdrawal

Black kidney transplant recipients have more acute rejection (AR) and inferior graft survival. We sought to determine whether early steroid withdrawal (ESW) had an impact on AR and death-censored graft loss (DCGL) in blacks. From 2006 to 2012, AR and graft survival were analyzed in 483 kidney recipients (208 black and 275 non-black). Rates of ESW were similar between blacks (65%) and non-blacks (67%). AR was defined as early (≤3 months) or late (>3 months). The impact of black race, early AR, and late AR on death-censored graft failure was analyzed using univariate and multivariate Cox models. Blacks had greater dialysis vintage, more deceased donor transplants, and less HLA matching, yet rates of early AR were comparable between blacks and non-blacks. However, black race was a risk factor for late AR (HR: 3.48 (95% CI: 1.87-6.47)) Blacks had a greater rate of DCGL, partially driven by late AR (HR with late AR: 5.6; 95% CI: 3.3-9.3). ESW had no significant interaction with black race for risk of early AR, late AR, or DCGL. Independent of ESW, black kidney recipients had a higher rate of late AR after kidney transplantation. Late AR was highly predictive of DCGL and contributed to inferior graft survival in blacks.

Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation

BACKGROUND AND OBJECTIVES

Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach.

RESULTS

States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons).

CONCLUSIONS

Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.

[Description of immunosuppressive maintenance treatments post kidney transplant through the National System of Health Insurance]

The aim of this study was to describe the drug dispensing of maintenance immunosuppression treatment in 2014 for patients who received a kidney transplant in 2012, based on the data of the French national health insurance and to compare those results with the information collected in the national database for kidney recipients. For each patient, are considered all drugs dispensing with their dates of issue, the molecules and their presentations (number of pills and dosage). Among 2463 transplanted adults in 2012, 73% have received tacrolimus monohydrate, 59% mycophenolate mofetil, 54% prednisone and 20% cyclosporin in 2014. The daily doses but not the number of tablets per day declined with age. The most frequent association was tacrolimus monohydrate-mycophenolate mofetil-steroids in 34% of the cases. The use of mTOR inhibitors, rare generally (7%), is more common in patients aged 66-85 years. Associations did not differ significantly according to diabetic status, for patients with a kidney from an elderly donor or according to the number of mismatch. The daily doses estimated from the deliverance in pharmacy are respectively similar, understated and over-estimate for tacrolimus, mycophenolate mofetil and cyclosporin compared to the national database. This study confirms the difficulty of apprehending drug consumption based only on dispensing in pharmacies or punctual recording even if it allows a fairly comprehensive view of French practices.

Multilevel factors are associated with immunosuppressant nonadherence in heart transplant recipients: The international BRIGHT study

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4-continent, 11-country cross-sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants-defined as any deviation in taking or timing adherence and/or dose reduction-was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale^© (BAASIS^© ) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health-related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out-of-pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels.

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.

Pharmacist's Role in Improving Medication Adherence in Transplant Recipients With Comorbid Psychiatric Disorders

Medication nonadherence rates are high in both the transplant and psychiatric populations. The consequence of medication nonadherence posttransplant is graft rejection and psychiatric decompensation, highlighting the importance of optimizing adherence to medication regimens. Pharmacists may work with transplant patients with psychiatric comorbidity to improve medication adherence through identifying patient-specific barriers and recommending an appropriate intervention. Multiple evidence-based practices for improving nonadherence have been detailed in the transplant and psychiatric population. Medication adherence aids, medication management, patient education, and motivational interviewing are all strategies that may be used to improve adherence. Selecting which interventions to make will be based on the reasons for a patient's nonadherence. Most patients benefit from medication management, patient education, and medication adherence aids. Selection of medication adherence aids may be based on patient demographics, technology literacy, and preference. Motivational interviewing may be considered in patients with intentional nonadherence relating to a lack of insight into their illness or the importance of taking medication. Pharmacists may promote adherence and potentially improve patient outcomes in transplant recipients with comorbid psychiatric disorders through assisting patients with designing a tailored medication adherence plan.

Adherence in pediatric kidney transplant recipients: solutions for the system

Non-adherence remains a significant problem among pediatric (and adult) renal transplant recipients. Non-adherence among solid organ transplant recipients results in US$15-100 million annual costs. Estimates of non-adherence range from 30 to 70% among pediatric patients. Research demonstrates that a 10% decrement in adherence is associated with 8% higher hazard of graft failure and mortality. Focus has begun to shift from patient factors that impact adherence to the contributing healthcare and systems factors. The purpose of this review is to describe problems within the systems implicated in non-adherence and potential solutions that may be related to positive adherence outcomes. Systems issues include insurance and legal regulations, provider and care team barriers to optimal care, and difficulties with transitioning to adult care. Potential solutions include recognition of how systems can work together to improve patient outcomes through improvements in insurance programs, a multi-disciplinary care team approach, evidence-based medical management, pharmacy-based applications and interventions to simplify medication regimens, improved transition protocols, and telehealth/technology-based multi-component interventions. However, there remains a significant lack of reliability in the application of these potential solutions to systems issues that impact patient adherence. Future efforts should accordingly focus on these efforts, likely by leveraging quality improvement and related principles, and on the investigation of the efficacy of these interventions to improve adherence and graft outcomes.

The prevalence, risk factors, and outcomes of medication trade-offs in kidney and liver transplant recipients: a pilot study

High out-of-pocket medication costs negatively impact adherence in transplantation. We evaluated the association of "medication trade-offs"-defined as choosing to spend money on other expenses over medications-with medication nonadherence and transplant outcomes. From 2011 to 2012, we performed a prospective study of 201 transplanted recipients (n = 103 liver, n = 98 kidney and) at two large US transplant centers. Structured interviews assessed socio-demographics, medication adherence, and medication trade-offs. Multivariable models assessing risk factors for medications trade-offs and the association between medications trade-offs and post-transplant hospital admissions were performed. A total of 17% of patients reported medication trade-offs; the most common trade-offs were inability to afford a prescription in the past 12 months and making choices between prescriptions and food. In multivariable analysis, insurance type (RR: 2.97, 95% CI: 1.19-7.40), limited health literacy (RR: 2.64, 95% CI: 1.23-5.64), and ≥3 comorbid conditions (RR: 2.48, 95% CI: 1.09-5.62; all P < 0.05) were associated with trade-offs. Patients with trade-offs were more likely to report nonadherence to medications (mean adherence: 77 ± 23% with trade-offs vs. 89 ± 19% without trade-offs, P < 0.01). The presence of medication trade-offs was associated with post-transplant hospital admissions (RR 1.64, 95% CI 1.14-2.35, P < 0.01). Assessments of financial barriers are warranted in clinical practice to identify nonadherence and improve post-transplant outcomes.

Tacrolimus Utilization and Expenditure in Serbia

Background

Increasing immunosuppressant consumption and expenditure is a quite a challenge in transplantation medicine. The aim of the study was to characterize the utilization and expenditure of tacrolimus, backbone, and standard of care in immunosuppression regimen in Serbian solid organ transplant recipients.

Methods

This study was performed as retrospective cross-sectional study during a 3-year period (from 2013 to 2015) in Serbia. The Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) international system was used for consumption evaluation.

Results

Two hundred and sixty-nine patients were transplanted in Serbia from 2013 to 2015 (185 recipients from deceased donors and 84 recipients from living donors). Total number of deceased donors in this period was 81. The consumption of tacrolimus increased (from 0.051 DDD/1,000 inhabitants/day to 0.069 DDD/1,000 inhabitants/day in 2013 and 2015, respectively). The total cost of tacrolimus was also increased; from 1,206,816€ to 1,483,472€ in 2013 and 2015, respectively. On the other hand, the number of all new solid organ transplants (from deceased and living donors) per million population per year was decreased from 17.39 to 10.02, from 2013 to 2015, respectively.

Conclusion

In spite downward trend in the number of solid organ transplants, tacrolimus consumption and expenditure in the examined 3-year period in Serbia increased. Since tacrolimus is a high-cost and life-preserving drug, its increasing utilization and expenditure will most likely continue consuming an enhancing share of Serbian pharmaceutical expenditure, as well as its health care, as a whole.

Association of Citizenship Status With Kidney Transplantation in Medicaid Patients

BACKGROUND

Although individuals classified as nonresident aliens, including undocumented immigrants, are entitled to receive emergency dialysis in the United States regardless of their ability to pay, most states do not provide them with subsidized care for maintenance dialysis or kidney transplantation. We explored whether nonresident aliens have similar outcomes to US citizens after receiving kidney transplants covered by Medicaid, a joint federal and state health insurance program.

STUDY DESIGN

Retrospective observational cohort study.

SETTING & PARTICIPANTS

All adult Medicaid patients in the US Renal Data System who received their first kidney transplant from 1990 to 2011.

PREDICTOR

Citizenship status, categorized as US citizen, nonresident alien, or permanent resident.

OUTCOME

All-cause transplant loss.

MEASUREMENTS

HRs and 95% CIs estimated by applying Cox proportional hazards frailty models with transplantation center as a random effect.

RESULTS

Of 10,495 patients, 8,660 (82%) were US citizens, 1,489 (14%) were permanent residents, and 346 (3%) were nonresident aliens, whom we assumed were undocumented immigrants. Nonresident aliens were younger, healthier, receiving dialysis longer, and more likely to have had a living donor. 71% underwent transplantation in California, and 61% underwent transplantation after 2005. Nonresident aliens had a lower unadjusted risk for transplant loss compared with US citizens (HR, 0.48; 95% CI, 0.35-0.65). Results were attenuated but still significant when adjusted for demographics, comorbid conditions, dialysis, and transplant-related factors (HR, 0.67; 95% CI, 0.46-0.94).

LIMITATIONS

Citizenship status was self-reported, possible residual confounding.

CONCLUSIONS

Our study suggests that the select group of insured nonresident aliens who undergo transplantation with Medicaid do just as well as US citizens with Medicaid. Policymakers should consider expanding coverage for kidney transplantation in nonresident aliens, including undocumented immigrants, given the associated high-quality outcomes in these patients.

Bioequivalence of twice-daily oral tacrolimus in transplant recipients: More evidence for consensus?

In this Perspective on the clinical trial by Rita Alloway and colleagues, Simon Ball explains the benefits to healthcare systems and individual patients of the bioequivalence established between generic and brand-name formulations of an immunosuppressive drug in transplant recipients.

Understanding Medication Nonadherence after Kidney Transplant

Alloimmunity remains a barrier to long-term graft survival that necessitates lifelong immunosuppressive therapy after renal transplant. Medication nonadherence has been increasingly recognized as a major impediment to achieving effective immunosuppression. Electronic medication monitoring further reveals that nonadherence manifests early after transplant, although the effect is delayed. The etiology of nonadherence is multifactorial, with the strongest risk factors including past nonadherence and being an adolescent or young adult. Other risk factors with smaller but consistently important effects include minority race/ethnicity, poor social supports, and poor perceived health. In children, risk factors related to parental and child psychologic and behavioral functioning and parental distress and burden are also important. Qualitative systematic reviews highlight the need to tailor interventions to each transplant recipient's unique needs, motivations, and barriers rather than offer a one size fits all approach. To date, relatively few interventions have been studied, and most studies conducted were underpowered to allow definitive conclusions. If the kidney transplant community's goal of "one transplant for life" is to become a reality, then solutions for medication nonadherence must be found and implemented.

Hypertension in the Kidney Transplant Recipient: Overview of Pathogenesis, Clinical Assessment, and Treatment

Cardiovascular disease is the leading cause of death in patients with chronic renal disease and the most common cause of death and allograft loss among kidney transplant recipients. Transplant patients often have multiple cardiovascular risk factors antedating transplantation. Among the most prominent is hypertension (HTN), which affects at least 90% of transplant patients. Uncontrolled HTN is an independent risk factor for allograft loss. The etiology of HTN in transplant recipients is complex and multifactorial, including the use of essential immunosuppressive medications. Post-transplant HTN management requires a systematic and individualized approach with nonpharmacologic and pharmacologic therapies. There is no single ideal agent or treatment algorithm. Patients should regularly monitor and record their blood pressure at home. Often, multiple antihypertensive drugs are needed to achieve a goal blood pressure of 120-140/70-90 mm Hg. As transplant recipients commonly must take 8 to 12 different medications daily, adherence must be continually encouraged and monitored. Special attention must be paid to potential drug side effects and drug interactions with immunosuppressive medications.

Old game, new players: Linking classical theories to new trends in transplant immunology

The evolutionary emergence of an efficient immune system has a fundamental role in our survival against pathogenic attacks. Nevertheless, this same protective mechanism may also establish a negative consequence in the setting of disorders such as autoimmunity and transplant rejection. In light of the latter, although research has long uncovered main concepts of allogeneic recognition, immune rejection is still the main obstacle to long-term graft survival. Therefore, in order to define effective therapies that prolong graft viability, it is essential that we understand the underlying mediators and mechanisms that participate in transplant rejection. This multifaceted process is characterized by diverse cellular and humoral participants with innate and adaptive functions that can determine the type of rejection or promote graft acceptance. Although a number of mediators of graft recognition have been described in traditional immunology, recent studies indicate that defining rigid roles for certain immune cells and factors may be more complicated than originally conceived. Current research has also targeted specific cells and drugs that regulate immune activation and induce tolerance. This review will give a broad view of the most recent understanding of the allogeneic inflammatory/tolerogenic response and current insights into cellular and drug therapies that modulate immune activation that may prove to be useful in the induction of tolerance in the clinical setting.

Infectious complications as the leading cause of death after kidney transplantation: analysis of more than 10,000 transplants from a single center

AIM

To identify specific causes of graft failure in a large sample of kidney transplant patients from a middle-income, developing country.

METHODS

Retrospective cohort study analyzing all consecutive single kidney transplants (KTs) performed at a single center in Brazil between January 1st 1998 and December 31st 2013. The database closing date was December 31st 2014.

RESULTS

Out of 10,400 KTs, there were 1191 (11.45%) deaths with a functioning graft, 40 cases (0.38%) of primary non-function (PNF) and 1417 cases (13.62%) of graft loss excluding death and PNF as the cause. Infectious complications (404 cases, 34% of all deaths) were the major cause of death. Most deaths due to infection occurred within the first year after transplantation (157 deaths, 38.86%). Immunologic mechanisms, comprising acute rejection and immune-mediated interstitial fibrosis/tubular atrophy (IF/TA), were responsible for 52% of all cases of graft failure not involving recipient death. Half of the losses by acute rejection occurred late after transplantation.

CONCLUSION

Contrary to what is observed in developed countries, infectious complications are the main challenge with kidney transplantation in Brazil. Non-adherence to treatment also appears to contribute significantly to long-term kidney graft loss. Strategies for improvement should focus on better compliance and a greater safety profile of immunosuppressive treatment.

Medication Adherence After Renal Transplantation-a Review of the Literature

BACKGROUND

Whether or not patients follow the advice given by their healthcare professional is commonly referred to as adherence. In the case of kidney transplantation, transplant recipients need to take immunosuppressive drugs on a regular basis to prevent rejection of their transplant. However, medication adherence can be problematic for many patients.

OBJECTIVES

This critical appraisal of evidence aimed to gain insights into factors contributing to adherence and non-adherence in recipients of kidney transplants, and to explore patients' perceptions regarding adherence to immunosuppression.

METHODS

A comprehensive literature search was performed using Medline, PsycInfo, the Joanna Briggs Institute, CINAHL and the Cochrane Library. Included were primary research studies or reviews of primary research, independent of their research paradigms, on adult kidney or kidney/pancreas transplant recipients published in English or German. Children or adolescents were not considered. No time-frame was applied RESULTS: Fifty-two papers were included in the review. All extracted findings of included papers were organised according to the five factors influencing medication-taking behaviour as defined by the World Health Organisation: social and economic factors; therapy-related factors; patient-related factors; condition-related factors; healthcare team and system-related factors.

CONCLUSION

Reasons for non-adherence after kidney transplantations are diverse. Attention is attracted by the fact that potentially modifiable factors such as social support, experiences on dialysis, side effects, features of the treatment regimen, intentions and beliefs, forgetfulness and mental health issues play a greater role than other factors in the development of medication non-adherence. Factors not related to patient characteristics seem to be under researched.

Why do Patients Forget to Take Immunosuppression Medications and Miss Appointments: Can a Mobile Phone App Help?

Background

Kidney transplant recipients must adhere to their immunosuppressive medication regimen. However, non-adherence remains a major problem.

Objective

The aim of this paper is to determine how kidney transplant recipients remember to take their medications, and assess their perception and beliefs about adherence to immunosuppressive medications and barriers to medication adherence. In addition, we aim to assess perception and beliefs about willingness to use a hypothetical, mobile phone app to improve adherence.

Methods

We conducted a qualitative study that included an average of three home or workplace visits of kidney transplant recipients (N=16) from a single urban transplant center.

Results

The qualitative study revealed that transplant recipients understood the importance of taking their immunosuppressive medications and this motivated them to take their medications. The visits showed that most participants have incorporated medication use into their daily lives and that any minor deviation from daily routines could result in non-adherence. Participants also reported other barriers to adherence. All participants were interested in using an app to remind them to take their medication; however, they reported potential barriers to using the app.

Conclusions

Although kidney transplant recipients understood the importance of medication adherence, there were significant barriers to maintaining adherence. Participants also reported interest in using a mobile phone app.

Patient survey to identify reasons for non-adherence and elicitation of quality of life concepts associated with immunosuppressant therapy in kidney transplant recipients

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.

Assessing Transplant Education Practices in Dialysis Centers: Comparing Educator Reported and Medicare Data

BACKGROUND AND OBJECTIVES

The Centers for Medicare & Medicaid Services (CMS) requires that dialysis centers inform new patients of their transplant options and document compliance using the CMS-2728 Medical Evidence Form (Form-2728). This study compared reports of transplant education for new dialysis patients reported to CMS with descriptions from transplant educators (predominantly dialysis nurses and social workers) of their centers' quantity of and specific educational practices. The goal was to determine what specific transplant education occurred and whether provision of transplant education was associated with center-level variation in transplant wait-listing rates.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Form-2728 data were drawn for 1558 incident dialysis patients at 170 centers in the Heartland Kidney Network (Iowa, Kansas, Missouri, and Nebraska) in 2009-2011; educators at these centers completed a survey describing their transplant educational practices. Educators' own survey responses were compared with Form-2728 reports for patients at each corresponding center. The association of quantity of transplant education practices used with wait-listing rates across dialysis centers was examined using multivariable negative binomial regression.

RESULTS

According to Form-2728, 77% of patients (n=1203) were informed of their transplant options within 45 days. Educators, who reported low levels of transplant knowledge themselves (six of 12 questions answered correctly), most commonly reported giving oral recommendations to begin transplant evaluation (988 informed patients educated, 81% of centers) and referrals to external transplant education programs (959 informed patients educated, 81% of centers). Only 18% reported having detailed discussions about transplant with their patients. Compared with others, centers that used more than three educational activities (incident rate ratio, 1.36; 95% confidence interval, 1.07 to 1.73) had higher transplant wait-listing rates.

CONCLUSIONS

While most educators inform new patients that transplant is an option, dialysis centers with higher wait-listing rates use multiple transplant education strategies.