• Tacrolimus
• adherence
• immunosuppression
• liver transplantation
• quality of life

• Adult
• Humans
• Tacrolimus/therapeutic use
• Follow-Up Studies
• Immunosuppressive Agents/therapeutic use
• Quality of Life
• Liver Transplantation
• Prospective Studies
• Medication Adherence
• Graft Rejection/prevention & control

Today, older adult patients routinely undergo kidney transplantation. To support graft survival, patients must take immunosuppressant medicines for the rest of their lives. The post-transplant medication regimen is complex, and barriers to medication taking are likely confounded by both functional and intrinsic changes associated with advancing age. To develop diverse and innovative approaches to support best health outcomes in this vulnerable age group, it is imperative that the degree to which patients’ needs are currently being met, be identified.

The aim of this study was to examine medication-taking behaviours of kidney transplant recipients transplanted at 60 years of age or older.

This qualitative study used semi-structured patient interviews to explore how kidney transplant recipients currently manage their immunosuppressant regimen and how they cope after transplantation with the complex routine. Data were themed using the principles of Grounded Theory methodology; with interviews conducted until data saturation was reached.

Quantitative information was collected from 14 participants who ranged in age from 66 to 77 years (at time of interview), and were prescribed a median of 13 (min: 10, max: 26) medicines. The main themes that emerged from the interview were variability in health literacy toward medicines, the importance of support networks, the need to adjust health expectations, factors that were motivators for self-care, different approaches to medication management, and different approaches to medication taking. Overall, it was found that patients prioritised medication taking above all else, and gratitude to their donor was a powerful motivator to adhere. However, strategies to support medication taking were sometimes ineffective when patients’ routine changed.

Future interventions should consider approaches to foster adaptable medication taking behaviours that stand up to changes in the day-to-day routine.

Medication taking is complicated in transplant recipients, due to the number of medicines that need to be taken and the complex nature of the treatment regimen. Challenges in older transplant recipients may be more pronounced and varied compared with younger adults. There are multiple factors that may impact medication taking in older adults and each requires consideration, including level of dependence, living arrangements, level of mobility and manual dexterity, vision and memory, and social situation. To better identify the gaps in support, patients’ current perspectives around medication taking and how they cope after transplantation must be explored. Therefore, this study aimed to identify how older adult transplant recipients currently manage their anti-rejection medicine regimen. Participants described several strategies around how they manage a complex medication regimen. These included cues such as an alarm and linking the time they should take their medication to already established habits such as eating meals. Most participants discussed at length their relationships, and it seems that these relationships are often crucial to post-transplant positivity. Additionally, extreme gratitude to the donor, relative improvement in their life quality (compared with the rapid deterioration in their health when on dialysis), and fear of consequences (particularly graft failure) were important facilitators of self-care and served as timely reminders to prioritise one’s own health. To foster more robust medication-taking habits, future education needs to be tailored to each individual patient and include details about how to link medication taking to already established routines (coined ‘habit stacking’).

• Health focus of control
• Kidney transplantation
• Self-efficacy
• Treatment adherence

To explore the relationship between determinants and posttransplant medication nonadherence (MNA) in adult kidney transplant recipients, and to examine the relationship between posttransplant MNA and clinical outcomes.

Using the World Health Organization's model, this retrospective, multicenter, correlational study examined the relationship between determinants, posttransplant MNA, and clinical outcomes in 16,671 adult kidney transplant recipients from the Cerner Health Facts national data warehouse.

With 12% MNA, those who were nonadherent were more likely to have the social/economic factors of being younger, single, Caucasian versus Hispanic race, have the condition-related factor of mental health/substance use disorder, and have the healthcare system-related factor of government/health maintenance organization/managed care insurance (p′s < 0.05). Bivariate correlations indicated both age (OR = 1.006, p=0.01) and mental health or substance use disorder diagnosis (OR = 1.26, p=0.04) were significant predictors of MNA. Patients were 0.6% more likely to be medication adherent for each year they increased in age and 26% more likely to be MNA if they were diagnosed with a mental health/substance use disorder. Nonadherent patients were less likely to be readmitted, but more likely to have complications after transplant and medication side effects (p′s < 0.01).

Using one of the largest samples of adult kidney transplant patients, our findings support the WHO model and move the body of medication adherence intervention research forward by clarifying the importance of focusing interventions not only on the patient but on multilevel determinants. Consistent with previous studies, MNA negatively impacts transplant outcomes.

• capacity
• equitable access
• ethics
• law and policy
• transplantation

• An evaluation index system
• Delphi survey technique
• Kidney transplant recipients
• Omaha system
• Transitional care

• Delphi Technique
• Humans
• Kidney Transplantation
• Quality of Life
• Transitional Care

• allogeneic hematopoietic cell transplantation
• immunosuppression
• medication adherence

Prevalence of immunosuppressant nonadherence in renal transplant recipients is high despite negative clinical outcomes associated with nonadherence. Simplification of dosing has been demonstrated to improve adherence in renal transplant recipients as measured through electronic monitoring and self-report.

The purpose of this study was to replicate and extend previous findings by measuring adherence with multiple methods in a Canadian sample.

The study design was a randomized controlled medication dosing trial in adult renal transplant patients. The trial length was 4 months.

This study was conducted within the Solid Organ Transplant (SOT) Clinic at Vancouver General Hospital (VGH; Vancouver, Canada).

A total of 46 adult renal recipients (at least 1 year post-transplant) were recruited through the SOT clinic. With 8 withdrawals, 38 individuals completed all phases of the study.

Medication adherence was measured for a period of 4 months using multiple methods, including electronic monitoring (MEMS [Medication Event Monitoring System]), pharmacy refill data (medication possession ratio [MPR]), and by self-report using the Adherence subscale of the Transplant Effects Questionnaire (TEQ).

Participants were randomized to twice-daily (n = 19) or once-daily tacrolimus dosing (n = 19) and followed over a 4-month period via monthly clinic study visits. Comparisons between the treatment groups were performed using the Mann-Whitney U and chi-square tests, for continuous and categorical variables, respectively.

As outlined in Table 3, the once-daily dosing group showed significantly better MEMS Dose Adherence (P = .001), whereas MEMS Timing Adherence showed a tendency toward better adherence for this group, but was not significant (P = .052). MEMS Days Adherent (P = .418), MPR% (P = .123), and self-reported adherence (P = .284) did not differ between the once- and twice-daily dosing groups when measured as continuous variables. The MPR% was significantly better for the once-daily dosing group when measured dichotomously but not continuously (P = .044). Notably, most of those exposed to once-daily dosing (63.2%) preferred this to the twice-daily regimen.

Limitations included small sample size and short follow-up period, precluding the examination of clinical outcome differences.

Results for dose adherence replicate the finding that dose simplification increases adherence to immunosuppressants as measured through electronic monitoring. Such an advantage for the once-daily dosing group was not seen across the 2 other electronic monitoring measurement variables (days and timing adherence). This study extends previous research by examining adherence in once versus twice-daily dosing via prescription refill data in a Canadian sample. Given the gravity of potential health outcomes associated with nonadherence, although results indicate inconsistencies in significance testing across measurement methods, the medium to large effect sizes seen in the data favoring better adherence with once-daily dosing provide an indication of the potential clinical significance of these findings.

This study was registered with ClinicalTrials.gov (NCT01334333) on April 11, 2011.

• Advagraf
• Prograf
• electronic monitoring
• medication adherence
• renal transplantation
• tacrolimus

• kidney
• medication adherence
• outcomes
• system change
• transplant

• Aged
• Humans
• Immunosuppressive Agents/administration & dosage
• Kidney Transplantation
• Medication Adherence

• T32 NR015426 NINR NIH HHS

• social support
• transplantation
• evaluation criteria
• systematic review
• psychosocial
• transplant outcomes
• meta-analysis
• disparities

• Graft Rejection/prevention & control
• Humans
• Kidney Transplantation
• Medication Adherence
• Social Support
• Transplant Recipients/psychology

• K23 AT009374 NCCIH NIH HHS
• KL2 TR001063 NCATS NIH HHS

• financial barriers
• kidney transplant
• liver transplant
• medication nonadherence
• outcomes

Current health policies emphasize the need for an equitable doctor-patient relationship, and this requires a certain level of patient empowerment. However, a systematic review of the empirical evidence on how empowerment affects medication adherence—the extent to which patients follow the physician’s prescription of medication intake—is still missing. The goal of this systematic review is to sum up current state-of-the-art knowledge concerning the relationship between patient empowerment and medication adherence across medical conditions. As our conceptualization defines health locus of control and self-efficacy as being crucial components of empowerment, we explored the relationship between these two constructs and medication adherence.

Relevant studies were retrieved through a comprehensive search of Medline and PsychINFO databases (1967 to 2017). In total, 4903 publications were identified. After applying inclusion and exclusion criteria and quality assessment, 154 articles were deemed relevant. Peer-reviewed articles, written in English, addressing the relationship between empowerment (predictor) and medication adherence (outcome) were included.

High levels of self-efficacy and Internal Health Locus of Control are consistently found to promote medication adherence. External control dimensions were found to have mainly negative (Chance and God attributed control beliefs) or ambiguous (Powerful others attributed control beliefs) links to adherence, except for Doctor Health Locus of Control which had a positive association with medication adherence. To fully capture how health locus of control dimensions influence medication adherence, the interaction between the sub-dimensions and the attitudinal symmetry between the doctor and patient, regarding the patient’s control over the disease management, can provide promising new alternatives.

The beneficial effect of patients’ high internal and concurrent physician-attributed control beliefs suggests that a so-called “joint empowerment” approach can be suitable in order to foster medication adherence, enabling us to address the question of control as a versatile component in the doctor-patient relationship.

• biomarkers
• graft rejection
• medication adherence

• Graft rejection
• Immunology
• Immunosuppressive agents
• Kidney transplant
• Medication adherence
• Medication compliance
• Prevention and control

• Kidney
• Medication adherence
• Transplantation

• Adherence
• Cost-effectiveness
• Outcomes
• Randomized controlled trial
• Transplantation

• Adult
• Behavior Control/methods
• Cost-Benefit Analysis
• Feedback
• Humans
• Immunosuppressive Agents/therapeutic use
• Kidney Transplantation
• Medication Adherence
• Research Design
• Social Support

• R01 DK093592 NIDDK NIH HHS
• National Institute of Diabetes and Digestive and Kidney Diseases (US)

Non-adherence is a priority public health concern. Non-adherence means not taking medications, missing medications, taking too much, not taking enough, wrong timing, wrong dose and/or wrong pill, but may also refer to missing appointments, not booking appointments, not doing blood work, not returning calls and/or refusal to follow the treatment regimen. In renal transplantation, adherence to immunosuppressive medication is a fundamental requisite in order to preserve graft function, since non-adherence is one of the main causes for late acute rejection, incomplete recovery after rejection treatment, chronic graft dysfunction, graft loss, and death. Transplantation failure due to treatment non-adherence is economically, socially, ethically and morally unjustifiable. This is a very prevalent issue: in some studies, its incidence is as high as 70% of patients. The self-reported nonadherence levels found in certain studies, including those performed immediately after transplantation show the need for early and continued intervention after kidney transplantation in order to maximise adherence and consequently clinical outcomes. There is not a single method to assess non adherence, thus combining several measures increases diagnostic accuracy. Electronic monitoring with a microdevice that records each time a pill bottle is opened is considered the “gold standard” for measuring adherence, but self-report at a confidential interview was the best measure of adherence. Thus non-adherence risk can be effectively assessed using clinically available assessment tools. Medication Adherence Scale, Brief Medical Questionnaire, Immunosuppressant Therapy Adherence Scale, Immunosuppressant Therapy Barrier Scale, Long-Term Medication Behavior Self-Efficacy Scale and Simplified Medication Adherence Questionnaire are some of the self-reported questionnaires. There are multiple factors associated with non-adherence in immunosuppressant therapy: Younger patients (adolescent, especially), poor health coverage, poor social support, unmarried, no family, non-Caucasian, immigrant, lower income, lower socioeconomic class, greater parental distress and lower family cohesion; complex medical regimens, higher number of drugs, longer time after transplant, toxicity, side effects, poor tolerance to medication, higher number of physicians involved, poor provider-patient rapport; psychological (dependency, high levels of anxiety and hostility, poorer behavioral functioning and greater distress in children) and psychiatric (depression) illnesses, low self-efficacy with medicine intake, perception of immunosuppressive therapy as not been necessary to preserve kidney function, forgetfulness, rebelliousness, poor perception of health, poor satisfaction, low Health-related Quality of life, addictions, lack of coping strategies and avoidance behavior; patient morbidity: comorbidity, receiving a transplant from a live donor, retransplantation, and non-insulin-dependent diabetes. The most frequent strategies to promote medication-taking must focus on modifiable risk factors. Reasons for non-adherence are complex and diverse and any successful intervention aimed at improving adherence must be multidimensional. Although effective intervention strategies are needed to improve immunosuppressant therapy adherence, few intervention studies have been conducted in the adult renal transplant population. In this study, we perform an exhaustive review of the different strategies reported in the literature. A number of key reasons for non-adherence are also provided.

• Adherence
• Transplantation outcomes
• Renal transplantation
• Immunosuppressive medication
• Health-related quality of life

• adherence
• kidney
• outcomes
• patient compliance
• transplant

• adherence
• graft loss
• kidney transplantation
• mortality
• nurses/nursing
• side effects
• social support

• longitudinal studies
• medication adherence
• psychosocial factors
• somatic and chronic diseases
• systematic review

Among kidney transplant recipients, non-adherence with immunosuppressive medications frequently precedes allograft loss. We sought to determine the prevalence and correlates of medication non-adherence among kidney transplant recipients.

We performed a single-center, cross-sectional study of kidney transplant recipients who were at least 6 months post-transplant. We measured self-reported adherence using the Immunosuppressive Therapy Adherence Scale (ITAS, which is scored from 0 to 12, where higher scores indicate increased adherence) and barriers to adherence using the Immunosuppressive Therapy Barriers Scale (ITBS). We also used validated scales to measure perceived stress, health literacy, anxiety, depression, and interpersonal support.

The 252 patients included in the study were 59.9% male, 27.0% Black, and at a median of 2.9 years post-transplant (interquartile range [IQR] 1.4-5.8). On the ITAS, 59.1% scored a perfect 12, 26.6% scored 10–11, and 14.3% scored 0–9. In univariate models, non-adherence (defined as ITAS score ≤9) was significantly associated with increased scores on scales for perceived stress (OR 1.12, 95% CI 1.01-1.25) and depression (OR 1.14, 95% CI 1.02-1.28), and with more self-reported barriers to adherence on the ITBS (OR 1.15, 95% CI 1.08-1.22). After adjusting for sociodemographic factors, stress and depression were not associated with non-adherence. Higher scores on the ITBS (corresponding to more self-described barriers to adherence) were associated with lower scores on the ITAS (P < 0.001). Several individual barriers were associated with non-adherence.

Among prevalent kidney transplant recipients, a minority is non-adherent. Practical barriers to adherence may serve as promising targets for future interventions.

• Adult
• Aged
• Cross-Sectional Studies
• Female
• Femininity
• Humans
• Intention
• Interpersonal Relations
• Male
• Medication Adherence/psychology
• Medication Therapy Management
• Middle Aged
• Organ Transplantation/psychology
• Postoperative Care/psychology
• Predictive Value of Tests
• Psychological Tests
• Psychological Theory
• Sex Factors
• Social Support
• Spouses/psychology
• Surveys and Questionnaires

• electronic monitoring
• kidney
• medication adherence
• randomized controlled trial
• transplantation

• Adult
• Early Intervention, Educational
• Feasibility Studies
• Female
• Graft Rejection/prevention & control
• Humans
• Immunosuppressive Agents/therapeutic use
• Kidney Transplantation/immunology
• Male
• Medication Adherence
• Middle Aged
• Patient Care Team
• Patient Compliance
• Pilot Projects
• Prognosis

• P30 NR003979 NINR NIH HHS
• P30 NR003979-15 NINR NIH HHS