Wadhwani Sharad Indur, Nichols Melissa, Klosterkemper Jarrad, Cirincione Ross, Whitesell Kim, Owen Derek, Rengering Rebecca, Walz Benjamin, Heubi James, Hooper David K
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Pediatr Qual Saf. 2020 May 13;5(3):e296. doi: 10.1097/pq9.0000000000000296. eCollection 2020 May-Jun.
Poor adherence to medication following pediatric liver transplantation remains a major challenge, with some estimates suggesting that 50% of adolescent liver transplant recipients exhibit reduced medication adherence. To date, no gold standard has emerged to address this challenge; however, system interventions are most likely to be successful. We sought to implement a system to identify and address adherence barriers in a liver transplant clinic.
Using structured quality improvement methods, including multiple plan-do-study-act cycles, we developed a system to screen for patients at risk of poor adherence, identify patient- and/or parent-reported barriers to adherence, and partner with patients to overcome identified barriers. We developed a process to track key outcomes, including the variability in tacrolimus trough levels and episodes of late acute cellular rejection.
The practice saw a total of 85 patients over 6 months, and about half were females. Over this period, the improvement team implemented this system-level process with high reliability (>90% of patients received the bundle of interventions). The most commonly identified adherence barrier by patients and caregivers was "forgetting." The second most commonly identified adherence barrier by patients was that the medication "gets in the way of their activities," whereas by caregivers, it was "difficulty swallowing pills."
We identified challenges and opportunities to screen for poor adherence and identify patient- and/or caregiver-reported barriers to immunosuppression adherence. Identifying such barriers and partnering with patients to overcome those barriers using patient-centered, barrier-specific interventions could improve long-term graft survival through improved medication adherence.
小儿肝移植后用药依从性差仍是一项重大挑战，一些估计表明，50%的青少年肝移植受者用药依从性降低。迄今为止，尚未出现应对这一挑战的金标准；然而，系统干预最有可能取得成功。我们试图在一家肝移植诊所实施一个系统，以识别并解决依从性障碍。
我们采用结构化质量改进方法，包括多个计划-执行-研究-行动循环，开发了一个系统，用于筛查依从性差风险的患者，识别患者和/或家长报告的依从性障碍，并与患者合作克服已识别的障碍。我们制定了一个流程来跟踪关键结果，包括他克莫司谷浓度的变异性和迟发性急性细胞排斥反应的发作情况。
在6个月内该诊所共接待了85名患者，其中约一半为女性。在此期间，改进团队以高可靠性实施了这一系统层面的流程（>90%的患者接受了一系列干预措施）。患者和护理人员最常识别出的依从性障碍是“忘记”。患者第二常识别出的依从性障碍是药物“妨碍他们的活动”，而护理人员则是“吞咽药丸困难”。
我们确定了筛查依从性差以及识别患者和/或护理人员报告的免疫抑制依从性障碍方面的挑战和机遇。识别这些障碍并通过以患者为中心、针对特定障碍的干预措施与患者合作克服这些障碍，可通过改善用药依从性提高长期移植物存活率。
