Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients.

BACKGROUND: Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy. OBJECTIVES: This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results. MAIN RESULTS: Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported. AUTHORS' CONCLUSIONS: Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

Developing a national undergraduate standardized curriculum for future healthcare professionals on "Making Every Contact Count" for chronic disease prevention in the Republic of Ireland.

This report describes the development of the first national undergraduate interprofessional standardized curriculum in chronic disease prevention for healthcare professionals in the Republic of Ireland. This project brought together for the first time all higher education institutions nationwide in a novel collaboration with the national health service i.e. the Health Service Executive (HSE), to develop a standardized national curriculum for undergraduate health care professions. The curriculum sits within the framework of Making Every Contact Count, the goal of which is to re-orientate health services to embed the ethos of prevention through lifestyle behavior change as part of the routine care of health professionals. The core focus of Making Every Contact Count is chronic disease prevention, targeting four main lifestyle risk factors for chronic disease; tobacco use, alcohol consumption, physical inactivity and unhealthy eating. Making Every Contact Count is a key component of Healthy Ireland, the Irish national framework for health and wellbeing. The aim of the curriculum is to prepare newly qualified health professionals with the skills needed to support patients to achieve lifestyle behavior change delivered as part of routine clinical care.

Priorities for developing stroke care in Ireland from the perspectives of stroke survivors, family carers and professionals involved in stroke care: A mixed methods study.

INTRODUCTION: Increasing numbers of people are living with stroke, due to population ageing and improved survival, leading to a need for evidence to inform future policy decision-making. This study aimed to engage with stakeholders in Ireland to identify priorities for stroke services development. METHODS: A sequential mixed methods design was used. Phase 1 (qualitative) was exploratory, involving initial priority gathering via an online qualitative survey and interviews, with stroke survivors, family/main carers, and professionals working in stroke care. Framework analysis was used to generate a long-list of improvements to stroke services. Phase 2 involved a quantitative survey, where stakeholders selected five priority improvements from the long-list. Results were discussed in a stakeholder meeting. RESULTS: In-depth interviews were completed with 18 survivors, 13 carers and 8 professionals, while 80 professionals took part in a qualitative survey (phase 1). Priority areas of care were identified and a long-list of 45 priority improvements was generated. In phase 2, 34 survivors, 19 family carers and 42 professionals completed a survey. The highest priority improvements (selected by >20% of respondents) were access to specialist neuro-rehabilitation, ongoing support for life after stroke, recruitment/retention of specialist staff, improved information and support for health system navigation, and access to specialist acute care. Stroke survivors/carers prioritised exploring ways to improve access for strokes with atypical presentation, while professionals prioritised specialist inpatient rehabilitation and early supported discharge. Neither group prioritised stroke prevention. Based on discussions in the stakeholder meeting (n = 12), it was decided that support for mental health should also be included as a priority. DISCUSSION: The development of stroke services benefits from exploring the priorities of those receiving and delivering stroke care. Findings emphasise the need for equitable access to high quality adequately-staffed services, particularly post-discharge, that are easy to navigate, with good communication, and effective information provision.

A protocol to evaluate the impact of embedding Public and Patient Involvement in a structured PhD program for stroke care.

Background: Embedding Public and Patient Involvement (PPI) in postgraduate research has been recognized as an important component of post-graduate training, providing research scholars with an awareness and a skillset in an area which prepares them for future roles as healthcare researchers. Improving Pathways for Acute STroke And Rehabilitation (iPASTAR) is a structured PhD training program [Collaborative Doctoral Award (CDA)] which aims to design a person-centered stroke pathway throughout the trajectory of stroke care, to optimize post-stroke health and wellbeing. PPI is embedded at all stages. Purpose: The iPASTAR research programme was strongly informed by a round-table PPI consultation process with individuals who experienced stroke and who provided broad representation across ages, gender, geographical locations (urban and rural) and the PhD themed areas of acute care, early supported discharge and lifestyle-based interventions after stroke. Four PhD scholars taking part in the CDA-iPASTAR now work collaboratively with four stroke champions, supported by a wider PPI advisory panel. Methods: This study will evaluate the process and impact of embedding PPI during a PhD program. We will conduct a longitudinal mixed-methods evaluation, conducting focus groups at 24, 36, and 48 months to explore the experiences of the key stakeholders involved. The participants will include PhD scholars, PPI partners (PPI Advisory Group and PPI Champions), PhD supervisors and a PPI manager. An independent researcher will conduct the evaluation. We will include focus groups, individual interviews and participant reflections. Qualitative data will be analyzed using thematic and content analysis, quantitative data will be analyzed using descriptive statistics. Discussion: PPI and patient voice initiatives bring together researchers, family, and people with health care issues into meaningful dialogue and allow the development of a patient-voice learning network. Embedding PPI training within a PhD program can build meaningful capacity in PPI partnerships in stroke research.

Does stroke health promotion increase awareness of appropriate behavioural response? Impact of the face, arm, speech and time (FAST) campaign on population knowledge of stroke risk factors, warning signs and emergency response.

INTRODUCTION: Inability to identify stroke warning signs accurately is an important cause of delay in seeking medical attention, leading to potential ineligibility for acute intervention. We report on post-campaign findings (wave 2) of national surveys to estimate changes in population knowledge following a media-based Face, Arm, Speech, Time stroke awareness campaign, comparing findings to those of a pre-campaign population survey (wave 1).Participants and methods: One thousand and ten randomly selected adults (18+) completed the Stroke Awareness Questionnaire on knowledge of warning signs, risk factors and response to stroke at wave 2 and findings were compared to wave 1 survey results. Logistic regression was used to examine the association between demographic characteristics and self-reported risk factors with knowledge of stroke and emergency response. RESULTS: No significant differences existed in the ability of respondents to define stroke or to identify two or more stroke risk factors between waves 1 and 2 surveys (71% and 70%, respectively). Respondents to the wave 2 survey were five times more likely (odds ratio 4.9, p < .001) than those responding at wave 1 to know at least two warning signs of stroke (67% vs. 31%, respectively), specifically those targeted by the Face, Arm, Speech, Time campaign. While significant improvement in intention to call an ambulance was noted (odds ratio 1.5, p < .001, 57% at wave 2 compared to 47% at wave 1), for almost half of respondents (43%) this would not have been their first response to stroke. Less than 5% of respondents to both surveys identified thrombolysis as an emergency treatment for stroke (3.9% at wave 2 compared to 1.8% at wave 1). DISCUSSION: Although significant improvements were made in several areas of stroke knowledge and intended response, awareness of acute stroke interventions was poor and intended behavioural response was suboptimal. CONCLUSION: Findings from this study indicate need for targeted campaigns to improve population understanding of the reasons underlying the importance of rapid emergency response to stroke.

"We don't have the infrastructure to support them at home": How health system inadequacies impact on long-term care admissions of people with dementia.

OBJECTIVES: The influence of healthcare system factors on long-term care admissions has received relatively little attention. We address this by examining how inadequacies in the healthcare system impact on long-term care admissions of people with dementia. This is done in the context of the Irish healthcare system. METHODS: Thirty-eight qualitative in-depth interviews with healthcare professionals and family carers were conducted. Interviews focused on participants' perceptions of the main factors which influence admission to long-term care. Interviews were analysed thematically. RESULTS: The findings suggest that long-term care admissions of people with dementia may be affected by inadequacies in the healthcare system in three ways. Firstly, participants regarded the economic crisis in Ireland to have exacerbated the under-resourcing of community care services. These services were also reported to be inequitable. Consequently, the effectiveness of community care was seen to be limited. Secondly, such limits in community care appear to increase acute hospital admissions. Finally, admission of people with dementia to acute hospitals was believed to accelerate the journey towards long-term care. CONCLUSIONS: Inadequacies in the healthcare system are reported to have a substantial impact on the threshold for long-term care admissions. The findings indicate that we cannot fully understand the factors that predict long-term care admission of people with dementia without accounting for healthcare system factors on the continuation of homecare.

Impact of Use of Intramedullary and Extramedullary Guides on Tibial Component Geometry in Total Knee Replacements: A Systematic Review and Meta-Analysis.

Mechanical guides in total knee arthroplasty are divided into intramedullary and extramedullary systems, designed to give accurate reference, to enable the surgeon to perform a tibial cut which is perpendicular to the mechanical axis. We conducted a systematic review and meta-analysis of levels 1 and 2 published data which directly compares the two methods of alignment, with outcomes of interest being the mean tibial component angle to the mechanical axis and the number of outliers from the optimal range. The PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidance was followed. A search was conducted of online databases Medline PubMed; EMBASE; ISI Web of Science, and the Cochrane library, using the Boolean search string ([intramedullary OR extramedullary] AND knee AND [arthroplasty OR replacement]). Numerical data pertaining to tibial component alignment (TCA), the mechanical tibiofemoral angle, the tibial slope, and the number of outliers from optimal TCA were collated, and used to establish pooled results. No constraints on the search in terms of year of publication or language were instituted. Intrastudy bias was assessed using the Jadad score for randomized controlled trials and the Newcastle Ottawa score for prospective cohort studies. A total of 1,896 titles were reviewed. Following abstract review and full review of relevant articles, 10 publications were included for analysis, of which 8 were suitable to include for meta-analysis. No trials showed a significant difference in the mean TCA. Two trials showed an increased number of outliers in the extramedullary group and two studies showed an increased number of outliers in the intramedullary group. Pooled data from studies which included these outcomes showed no advantage for either system in limiting the number of outliers from the optimal TCA (relative risk, 0.99; 95% confidence interval [CI], 0.87-1.14; p = 0.004), and no significant difference in mean TCA (standardized mean difference, -0.07; 95% CI, -0.22 to 0.08; p = 0.000). Based on our results, no advantage can be attributed to the type of mechanical guide used in obtaining an adequate tibial cut.

Stroke warning campaigns: delivering better patient outcomes? A systematic review.

BACKGROUND: Patient delay in presenting to hospital with stroke symptoms remains one of the major barriers to thrombolysis treatment, leading to its suboptimal use internationally. Educational interventions such as mass media campaigns and community initiatives aim to reduce patient delays by promoting the signs and symptoms of a stroke, but no consistent evidence exists to show that such interventions result in appropriate behavioral responses to stroke symptoms. METHODS: A systematic literature search and narrative synthesis were conducted to examine whether public educational interventions were successful in the reduction of patient delay to hospital presentation with stroke symptoms. Three databases, MEDLINE, CINAHL, and PsycINFO, were searched to identify quantitative studies with measurable behavioral end points, including time to hospital presentation, thrombolysis rates, ambulance use, and emergency department (ED) presentations with stroke. RESULTS: Fifteen studies met the inclusion criteria: one randomized controlled trial, two time series analyses, three controlled before and after studies, five uncontrolled before and after studies, two retrospective observational studies, and two prospective observational studies. Studies were heterogeneous in quality; thus, meta-analysis was not feasible. Thirteen studies examined prehospital delay, with ten studies reporting a significant reduction in delay times, with a varied magnitude of effect. Eight studies examined thrombolysis rates, with only three studies reporting a statistically significant increase in thrombolysis administration. Five studies examined ambulance usage, and four reported a statistically significant increase in ambulance transports following the intervention. Three studies examining ED presentations reported significantly increased ED presentations following intervention. Public educational interventions varied widely on type, duration, and content, with description of intervention development largely absent from studies, limiting the potential replication of successful interventions. CONCLUSIONS: Positive intervention effects were reported in the majority of studies; however, methodological weaknesses evident in a number of studies limited the generalizability of the observed effects. Reporting of specific intervention design was suboptimal and impeded the identification of key intervention components for reducing patient delay. The parallel delivery of public and professional interventions further limited the identification of successful intervention components. A lack of studies of sound methodological quality using, at a minimum, a controlled before and after design was identified in this review, and thus studies incorporating a rigorous study design are required to strengthen the evidence for public interventions to reduce patient delay in stroke. The potential clinical benefits of public interventions are far-reaching, and the challenge remains in translating knowledge improvements and correct behavioral intentions to appropriate behavior when stroke occurs.

Understanding communication of health information: a lesson in health literacy for junior medical and physiotherapy students.

Best practice communication between healthcare professionals and patients involves using quality patient information leaflets (PILs). We assessed medical and physiotherapy students' (N = 337) ability to appraise the readability, psychology theory content and quality of nine international smoking PILs. Flesch scores ranged from 52.8-79.7% (fairly difficult to fairly easy). Students identified components of the Health Belief Model (84-98%), Theory of Planned Behaviour (65-88%) and Transtheoretical Model (37-86%). Importantly, student-proposed additional theory-based content had no detrimental effect on readability scores. Overall quality scores indicated low-moderate quality. This assignment helped students critically evaluate the utility of PILs for communication.