Improving medication adherence and outcomes in adult kidney transplant patients using a personal systems approach: SystemCHANGE™ results of the MAGIC randomized clinical trial.

This study determined if a SystemCHANGE™ intervention was more efficacious than attention control in increasing immunosuppressive medication adherence and improving outcomes in adult kidney transplant recipients during a 6-month intervention phase and subsequent 6-month (no intervention) maintenance phase. The SystemCHANGE™ intervention taught patients to use person-level quality improvement strategies to link adherence to established daily routines, environmental cues, and supportive people. Eighty-nine patients (average age 51.8 years, 58% male, 61% African American) completed the 6-month intervention phase. Using an intent-to-treat analysis, at 6 months, medication adherence for SystemCHANGE™ (median 0.91, IQR 0.76-0.96) and attention control (median 0.67, IQR 0.52-0.72) patients differed markedly (difference in medians 0.24, 95% CI 0.13-0.30, P < .001). At the conclusion of the subsequent 6-month maintenance phase, the gap between medication adherence for SystemCHANGE™ (median 0.77, IQR 0.56-0.94) and attention control (median 0.60, IQR 0.44-0.73) patients remained large (difference in medians 0.17, 95% CI 0.06-0.33, P = .004). SystemCHANGE™ patients evidenced lower mean creatinine and BUN at 12 months and more infections at 6 and 12 months. This first fully powered RCT testing SystemCHANGE™ to improve and maintain medication adherence in kidney transplant recipients demonstrated large, clinically meaningful improvements in medication adherence. Clinical Trial Registration: NCT02416479.

Time-in-a-bottle (TIAB): a longitudinal, correlational study of patterns, potential predictors, and outcomes of immunosuppressive medication adherence in adult kidney transplant recipients.

This study examined patterns, potential predictors, and outcomes of immunosuppressive medication adherence in a convenience sample of 121 kidney transplant recipients aged 21 yr or older from three kidney transplant centers using a theory-based, descriptive, correlational, longitudinal design. Electronic monitoring was conducted for 12 months using electronic monitoring. Participants were persistent in taking their immunosuppressive medications, but execution, which includes both taking and timing, was poor. Older age was the only demographic variable associated with medication adherence (r = 0.25; p = 0.005). Of the potential predictors examined, only medication self-efficacy was associated with medication non-adherence, explaining about 9% of the variance (r = 0.31, p = 0.0006). The few poor outcomes that occurred were not significantly associated with medication non-adherence, although the small number of poor outcomes may have limited our ability to detect a link. Future research should test fully powered, theory-based, experimental interventions that include a medication self-efficacy component.

Cost-Effectiveness Analysis: Personal Systems Approach in Improving Medication Adherence in Adult Kidney Transplant Patients.

ABSTRACT: Interventions to improve medication nonadherence in transplantation have recently moved from a focus on motivation and intention, to a focus on person-level quality improvement strategies. These strategies link adherence to established daily routines, environmental cues, and supportive people. The objective of this evaluation was to estimate the cost of implementation and the cost-effectiveness of a person-level intervention shown to increase medication adherence. To estimate the intervention costs, a direct measure microcosting approach was used after key informant interviews with project champions and a review of implementation expenditures. Cost-effectiveness was calculated by comparing the incremental implementation costs and healthcare costs associated with nonadherence to the incremental percent adherent, defined as the percent of patients who took greater or equal to 85% of their medication doses, for each pairwise comparison. The intervention was low-resource to implement, costing approximately $520 to implement per patient, and was associated with significant improvements in medication adherence. These implementation costs were more than outweighed by the expected healthcare savings associated with improvements in adherence. This person-level intervention is a low-cost, efficacious intervention associated with significant statistical and clinical improvements in medication adherence in adult kidney transplant recipients.

Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients.

BACKGROUND: Immunosuppressive medication non-adherence is one of the most prevalent but preventable causes of poor outcomes in adult renal transplant recipients, yet there is a paucity of studies testing interventions in this area. METHODS: Using a randomized controlled trial design, 30 adult renal transplant recipients were screened for medication non-adherence using electronic monitoring. Fifteen non-adherent participants were randomized to receive either a continuous self-improvement intervention or attention control management. The six-month continuous self-improvement intervention involved the participant and clinical nurse specialist collaboratively identifying the person's life routines, important people, and possible solutions to enhance medication taking. The participant then received individual monthly medication taking feedback delivered via a graphic printout of daily medication taking generated from electronic monitoring. RESULTS: The mean medication adherence score for the continuous self-improvement intervention group (n = 8) was statistically significantly higher than the attention control group's (n = 5) mean medication adherence score (p = 0.03). The continuous self-improvement intervention effect size (Cohen's d) was large at 1.4. Participants' perceptions of the intervention were highly favorable. CONCLUSIONS: The continuous self-improvement intervention shows promise as an effective and feasible approach to improve medication adherence in adult renal transplant recipients. A fully-powered study with a diverse sample is needed to confirm these preliminary findings.

Medication adherence and older renal transplant patients' perceptions of electronic medication monitoring.

This study evaluated older renal transplant recipients' perceptions of electronic medication monitoring and the influence of these perceptions on medication adherence. A sample of 73 older adult renal transplant recipients who used the Medication Event Monitoring System (MEMS(®)) TrackCaps for 12 months provided their perceptions of device use. Participants perceived that the MEMS had a neutral effect on their medication-taking routine (65%), believed the MEMS was practical (56%), and could not describe any instances in which using the MEMS was difficult (56%). No significant difference in medication adherence was found between those who perceived the MEMS's influence negatively/neutrally and those who perceived the MEMS positively (p = 0.22). Medication adherence data from older adult renal transplant recipients can be used regardless of their perceptions of the MEMS's influence on their medication taking without biasing medication adherence data.

Intrasubject medication adherence patterns.

The purpose of this prospective descriptive study was to explore the patterns of intrasubject (between medication) adherence of two similarly timed, twice-daily medications using the Medication Event Management System electronic monitoring cap. Medication adherence was measured for 6 months using electronic monitoring in 25 adult renal-transplant recipients. Data were available from 7,119 electronic medication events. Results indicated that two twice-daily medications scheduled to be taken simultaneously were taken within 5 min of each other 77% of the time and within 10 min, 92% of the time. When only the first scheduled dose of the day was examined, the results are 79% and 95%, respectively. These findings are important to researchers and clinicians who must evaluate medication adherence in transplant recipients while balancing cost and subject burden. This study provides empirical support for monitoring a single immunosuppressive medication electronically to estimate medication adherence with double or triple immunosuppressive drug therapy.

Medication-taking beliefs of adult renal transplant recipients.

PURPOSE: To describe the medication-taking beliefs of younger and older adult renal transplant recipients. METHOD: A descriptive design was used to study 16 adult renal transplant recipients, 8 older and 8 younger, recruited from a renal transplant program in the midwest. A semistructured interview was conducted based on the theory of planned behavior. Data were examined using manifest content analyses. RESULTS: Both groups had similar behavioral, normative, control, and problem-solving medication-taking beliefs. Planning ahead, organizing, using cues, involving a support person, and remembering the donor and life on dialysis were key control beliefs. Differences were found in beliefs regarding difficulties with taking immunosuppressive medications. The majority in both groups mentioned forgetting to take their immunosuppressive medications on at least one occasion. CONCLUSIONS/APPLICATION: As empiric evidence in this area grows, the clinical nurse specialist is paramount in assisting both younger and older renal transplant recipients with immunosuppressive medication taking and, consequently, in fostering better outcomes.

Medication adherence patterns in adult renal transplant recipients.

Patient adherence to immunosuppressive medications adherence is crucial to survival of the patient and a transplanted kidney, yet adherence is variable. Using a prospective, descriptive design, immunosuppressive medication adherence of 44 renal transplant recipients was followed for 6 months at a Midwestern transplant center using electronic monitoring. Four medication adherence patterns emerged from a hierarchical cluster analysis: those who took medications on time, those who took medications on time with late/missed doses, those who rarely took medications on time and who were late with morning and/or evening doses, and those who missed doses. This study is a step toward developing and implementing interventions targeted to specific patterns of poor adherence.