Annette DeVito Dabbs

Rates and risk factors for nonadherence to the medical regimen after adult solid organ transplantation.

Background. Despite the impact of medical regimen nonadherence on health outcomes after organ transplantation, there is mixed and conflicting evidence regarding the prevalence and predictors of posttransplant nonadherence. Clinicians require precise information on nonadherence rates in order to evaluate patients’ risks for this problem. Methods. A total of 147 studies of kidney, heart, liver, pancreas/kidney-pancreas, or lung/heart-lung recipients published between 1981 and 2005 were included in a meta-analysis. Average nonadherence rates were calculated for 10 areas of the medical regimen. Correlations between nonadherence and patient psychosocial risk factors were examined. Results. Across all types of transplantation, average nonadherence rates ranged from 1 to 4 cases per 100 patients per year (PPY) for substance use (tobacco, alcohol, illicit drugs), to 19 to 25 cases per 100 PPY for nonadherence to immunosuppressants, diet, exercise, and other healthcare requirements. Rates varied significantly by transplant type in two areas: immunosuppressant nonadherence was highest in kidney recipients (36 cases per 100 PPY vs. 7 to 15 cases in other recipients). Failure to exercise was highest in heart recipients (34 cases per 100 PPY vs. 9 to 22 cases in other recipients). Demographics, social support, and perceived health showed little correlation with nonadherence. Pretransplant substance use predicted posttransplant use. Conclusions. The estimated nonadherence rates, overall and by transplant type, allow clinicians to gauge patient risk and target resources accordingly. Nonadherence rates in some areas—including immunosuppressant use—appear unacceptably high. Weak correlations of most patient psychosocial factors with nonadherence suggest that attention should focus on other classes of variables (e.g., provider-related and systems-level factors), which may be more influential.

Meta-Analysis of Risk for Relapse to Substance Use After Transplantation of the Liver or Other Solid Organs

For patients receiving liver or other organ transplants for diseases associated with substance use, risk for relapse posttransplantation is a prominent clinical concern. However, there is little consensus regarding either the prevalence or risk factors for relapse to alcohol or illicit drug use in these patients. Moreover, the evidence is inconsistent as to whether patients with pretransplantation substance use histories show poorer posttransplantation medical adherence. We conducted a meta‐analysis of studies published between 1983 and 2005 to estimate relapse rates, rates of nonadherence to the medical regimen, and the association of potential risk factors with these rates. The analysis included 54 studies (50 liver, 3 kidney, and 1 heart). Average alcohol relapse rates (examined only in liver studies) were 5.6 cases per 100 patients per year (PPY) for relapse to any alcohol use and 2.5 cases per 100 PPY for relapse with heavy alcohol use. Illicit drug relapse averaged 3.7 cases per 100 PPY, with a significantly lower rate in liver vs. other recipients (1.9 vs. 6.1 cases). Average rates in other areas (tobacco use, immunosuppressant and clinic appointment nonadherence) were 2 to 10 cases per 100 PPY. Risk factors could be examined only for relapse to any alcohol use. Demographics and most pretransplantation characteristics showed little correlation with relapse. Poorer social support, family alcohol history, and pretransplantation abstinence of ≤6 months showed small but significant associations with relapse (r = 0.17‐0.21). Future research should focus on improving the prediction of risk for substance use relapse, and on testing interventions to promote continued abstinence posttransplantation. Liver Transpl 14:159–172. 2008.

User-Centered Design and Interactive Health Technologies for Patients

Despite recommendations that patients be involved in the design and testing of health technologies, few reports describe how to involve patients in systematic and meaningful ways to ensure that applications are customized to meet their needs. User-centered design is an approach that involves end users throughout the development process so that technologies support tasks, are easy to operate, and are of value to users. In this article, we provide an overview of user-centered design and use the development of Pocket Personal Assistant for Tracking Health (Pocket PATH) to illustrate how these principles and techniques were applied to involve patients in the development of this interactive health technology. Involving patient-users in the design and testing ensured functionality and usability, therefore increasing the likelihood of promoting the intended health outcomes.

Meta-Analysis of Medical Regimen Adherence Outcomes in Pediatric Solid Organ Transplantation*

Background. Adherence to the medical regimen after pediatric organ transplantation is important for maximizing good clinical outcomes. However, the literature provides inconsistent evidence regarding prevalence and risk factors for nonadherence posttransplant. Methods. A total of 61 studies (30 kidney, 18 liver, 8 heart, 2 lung/heart-lung, and 3 with mixed recipient samples) were included in a meta-analysis. Average rates of nonadherence to six areas of the regimen, and correlations of potential risk factors with nonadherence, were calculated. Results. Across all types of transplantation, nonadherence to clinic appointments and tests was most prevalent, at 12.9 cases per 100 patients per year (PPY). The immunosuppression nonadherence rate was six cases per 100 PPY. Nonadherence to substance use restrictions, diet, exercise, and other healthcare requirements ranged from 0.6 to 8 cases per 100 PPY. Only the rate of nonadherence to clinic appointments and tests varied by transplant type: heart recipients had the lowest rate (4.6 cases per 100 PPY vs. 12.7–18.8 cases per 100 PPY in other recipients). Older age of the child, family functioning (greater parental distress and lower family cohesion), and the child’s psychological status (poorer behavioral functioning and greater distress) were among the psychosocial characteristics significantly correlated with poorer adherence. These correlations were small to modest in size (r=0.12–0.18). Conclusions. These nonadherence rates provide benchmarks for clinicians to use to estimate patient risk. The identified psychosocial correlates of nonadherence are potential targets for intervention. Future studies should focus on improving the prediction of nonadherence risk and on testing interventions to reduce risk.

Adherence to the medical regimen during the first two years after lung transplantation.

Background. Despite the importance of adherence to the medical regimen for maximizing health after lung transplantation, no prospective studies report on rates or risk factors for nonadherence in this patient population. Whether adherence levels differ in lung versus other types of transplant recipients is unknown. Methods. A total of 178 lung recipients and a comparison group of 126 heart recipients were enrolled. Adherence in nine areas was assessed in separate patient and family caregiver interviews 2, 7, 12, 18, and 24 months posttransplant. Potential risk factors for nonadherence were obtained at the initial assessment. Results. Cumulative incidence rates of persistent nonadherence (i.e., nonadherence at ≥2 consecutive assessments) were significantly lower (P<0.05) in lung recipients than heart recipients for taking immunosuppressants (13% nonadherent vs. 21%, respectively), diet (34% vs. 56%), and smoking (1% vs. 8%). Lung recipients had significantly higher persistent nonadherence to completing blood work (28% vs. 17%) and monitoring blood pressure (70% vs. 59%). They had a high rate of spirometry nonadherence (62%; not measured in heart recipients). The groups did not differ in nonadherence to attending clinic appointments (27%), exercise (44%), or alcohol limitations (7%). In both groups, poor caregiver support and having only public insurance (e.g., Medicaid) increased nonadherence risk in all areas. Conclusions. Lung recipients were neither uniformly better nor worse than heart recipients in adhering to their regimen. Lung recipients have particular difficulty with some home monitoring activities. Strategies to maximize adherence in both groups should build on caregiver support and on strengthening financial resources for patient healthcare requirements.

Exemplars of mixed methods data combination and analysis

Background: Mixed methods research approaches can be applied to nursing and healthcare. Multiple perspectives and different types of data (e.g., social-behavioral data, numerical outcome measures, or clinical variables) often are needed to examine complex clinical problems and health behaviors fully. Although qualitative and quantitative methods are recognized widely as complementary for studying and explaining human phenomena, methodological techniques for combining and analyzing mixed methods data have received less attention. Objectives: To describe techniques for mixed methods data combination and analyses using three different design approaches. Methods: Data combination and analysis techniques are presented using the following approaches: (a) mixed methods event analysis, (b) concurrent-mixed analysis for complementarity and completeness, and (c) concurrent nested analysis to provide a broader understanding of phenomena and enrich the description of participants. Results: Research exemplars from topical areas such as weaning from long-term mechanical ventilation, medication-taking among community-dwelling persons with dementia, health control beliefs after lung transplantation, and recovery from subarachnoid hemorrhage are presented. Simple and complex matrix construction and a variety of graphical displays are used to illustrate data combination and analysis techniques for mixed methods research. Discussion: The techniques for mixed methods data combination and analysis presented have the potential to advance the use and refinement of mixed methods research, thereby expanding the repertoire of methodologies to study complex phenomena of interest to nurses.

Evaluation of a hand‐held, computer‐based intervention to promote early self‐care behaviors after lung transplant

Abstract:  Background:  Lung transplant recipients are expected to perform self‐care behaviors to maximize transplant‐related health outcomes. Despite high non‐adherence rates in performing these self‐care behaviors, and the dire clinical consequences of such non‐adherence, interventions are lacking. Pocket Personal Assistant for Tracking Health (Pocket PATH) is a hand‐held device developed for patients to record health data, review data trends, and report condition changes to the transplant team.

Anxiety and Agitation in Mechanically Ventilated Patients

During an ethnography conducted in an intensive care unit (ICU), we found that anxiety and agitation occurred frequently and were important considerations in the care of 30 patients weaning from prolonged mechanical ventilation. We conducted a secondary analysis to (a) describe characteristics of anxiety and agitation experienced by mechanically ventilated patients, (b) explore how clinicians recognized and interpreted anxiety and agitation, and (c) describe strategies and interventions used to manage anxiety and agitation with mechanically ventilated patients. We constructed the Anxiety/Agitation in Mechanical Ventilation Model to illustrate the multidimensional features of symptom recognition and management. Patients’ ability to interact with the environment served as a basis for identification and management of anxiety or agitation. Clinicians’ attributions about anxiety or agitation, and “knowing the patient,” contributed to their assessment of patient responses. Clinicians chose strategies to overcome either the stimulus or the patient’s appraisal of risk of the stimulus. This article contributes to the body of knowledge about symptom recognition and management in the ICU by providing a comprehensive model to guide future research and practice.

Palliative care referrals after lung transplantation in major transplant centers in the United States.

Objective: Although lung transplantation is a widely used treatment modality for patients with end-stage lung disease, its long-term outcomes are limited. Including palliative approaches in the care of lung transplant recipients may be beneficial; however, systematic information regarding the utilization of palliative care services for lung recipients is lacking. Design and Setting: Of the 27 transplant centers meeting the inclusion criteria (an annual lung transplant volume ≥15 for the past 5 years and the availability of palliative care or pain services at the center), 74 clinicians representing either the transplant or palliative care program from 18 centers completed surveys. Results: Both transplant and palliative care clinician respondents strongly favored the idea of integrating palliative care into lung transplant care. However, the number of palliative care referrals made during the last year was low (≤5 per center). The three most frequently endorsed reasons for palliative care referrals were end-of-life planning, uncontrolled pain and symptoms, and limited functional status. The average length of survival after referral was <30 days. Palliative care clinicians considered misconceptions that palliative care meant “end-of-life care” as a major barrier, whereas transplant clinicians identified uncertainty about recipients’ prognoses, the perception that palliative care precludes aggressive treatment, and difficulty in discussing palliative care with recipients and family as barriers. Conclusions: Despite clinicians’ positive attitudes toward integrating palliative and lung transplant care, actual utilization of palliative care services is low. Collaborative efforts to enhance communication between the two programs are needed to clarify misconceptions and promote understanding between the programs.

Medical adherence in pediatric organ transplantation: what are the next steps?

Purpose of reviewAdherence within pediatric transplantation has gained importance as the complexities of long-term medical management of these patients are identified and knowledge regarding the negative consequences of nonadherence accumulates. We review recent findings to highlight gaps in the literature and make suggestions for future directions. Recent findingsMost research has focused on medication nonadherence, and a recent meta-analysis indicates that nonadherence is more prevalent in adolescent transplant recipients than in younger children. Nonadherence to other areas of the regimen (e.g. clinic attendance) may be even more common than medication nonadherence. However, work to date is based primarily on kidney and liver pediatric transplant patients, with a paucity of research on heart, lung and intestinal recipients. Risk factors for nonadherence after pediatric transplantation include poor family and child functioning. Intervention research remains rare. Challenges include the need for clearer definitions of what constitutes clinically significant nonadherence, longitudinal and prospective assessment of a wider range of potential risk factors, and the development and evaluation of interventions to treat or prevent nonadherence. SummaryAdherence research in pediatric transplantation is in its infancy. Significant opportunities exist to advance the field and create standards for effective identification, measurement, and treatment of nonadherence.