This literature review summarizes the evidence on the prevalence, determinants, clinical and economic consequences of nonadherence with immunosuppressive drugs in renal transplant patients. A literature search yielded 38 articles measuring nonadherence by self-report, collateral report, assay, refill prescriptions or electronic monitoring. The weighted mean prevalence of self-reported nonadherence was 28%. Nonadherence is associated with poor clinical outcomes, contributing to 20% of late acute rejection episodes and 16% of the graft losses (weighted means). In addition, nonadherence results in lower lifetime costs because of shorter survival, yet also in a lower number of quality adjusted life years. Consistent determinants of nonadherence were younger age, social isolation, and cognitions (e.g. low self-efficacy, certain health beliefs). Determinants concerning the health care system/team seem to be under-investigated. Because the evidence summarized in this review is based on older immunosuppressive regimens, further research should focus on prevalence, determinants and consequences of nonadherence with newer immunosuppressive regimens.

This guideline, structured around 4 minimum criteria and 17 items reflecting best practice, aims to help researchers improve the quality of reporting medication adherence research. Research on assessing or managing medication adherence applies approaches from observational, interventional, and implementation science that spans many disciplines and demands coherent conceptuali...

Objectives To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.

Reports of interventions to improve adherence to medical regimens in solid organ transplant recipients are scarce. A systematic review identified 12 intervention studies. These studies focused on renal, heart, and liver transplant recipients. Five reports used randomized controlled trial (RCT) designs. Sample sizes varied between 18 and 110 subjects. The interventions are difficult to evaluate and categorize because of brief descriptions of intervention details. Of the 12 studies identified in this review, only five studies found a statistically significant improvement in at least one medication-adherence outcome with the intervention. In general, most included a combination of patient-focused cognitive/educational, counseling/behavioral, and psychologic/affective dimensions. Eight studies intervened at the healthcare provider, healthcare setting or healthcare system level, but showed a limited improvement in adherence. No single intervention proved to be superior at increasing medication-adherence in organ transplantation, but a combination of interventions in a team approach for the chronic disease management of organ transplant patients may be effective in a long-term perspective. In conclusion, finding the most effective combination of interventions to enhance adherence is vital. Utilizing an RCT design and adhering to the CONSORT guidelines can lead to higher quality studies and possibly more effective intervention studies to enhance medication-adherence.

Non-adherence with immunosuppressive regimen is a major risk factor for poor outcome after kidney transplantation. Identifying patients at risk for non-adherence requires understanding the risk factors for non-adherence. This prospective study included a convenience sample of 249 adult kidney transplant patients >1 year post-transplant. Non-adherence was monitored electronically using MEMS®. Selected socio-economic, therapy-, patient-, condition- and healthcare team-related risk factors for non-adherence were assessed. Period prevalences were expressed as the percent of prescribed doses taken (taking adherence), the percent of correctly dosed days (dosing adherence), the percentage of inter-dose intervals not exceeding 25% of the prescribed interval (timing adherence), and the number of drug holidays per 100 days (no intake for > 48 h if once daily or for > 24 h if twice daily intake). Testing occurred by simple mixed logistic regression analysis. Factors significant after correction for multiple testing were entered into a multiple logistic regression model. Mean taking, dosing, timing adherence, and drug holidays were 98%, 96%, 93%, and 1.1 days, respectively. Non-adherence was associated with lower self-efficacy, higher self-reported non-adherence, no pillbox usage, and male gender. Adherence declined between Monday and Sunday. This study provides a framework for identifying patients at risk for non-adherence and for developing adherence-enhancing interventions.

Valid assessment of immunosuppressive therapy non-adherence (NAH) is vital: NAH is associated with negative transplantation outcomes. We studied the diagnostic accuracy of assay, patient self-reports and clinicians' collateral reports and composite adherence scores using electronic monitoring (EM) as a reference standard. This cross-sectional study included a convenience sample of 249 adult kidney transplant recipients (Ktx) (female: 43.4%; mean age 53.6 [SD: 12.7], median 7 years [IQR: 9 years] post-Ktx). NAH was assessed using EM over 3 months (i.e. reference standard), assays of cyclosporine, tacrolimus, mycophenolat-mofetil, patients' self-reports and clinicians' collateral reports. The constructed composite adherence score included assay, self-reports and collateral reports. NAH's prevalence across the measurement methods was EM: 17.3%; assay: 33% (cyclosporine: 25.8%; tacrolimus: 35.1%; mycophenolat-mofetil: 40.2%); self-report: 12.4%; collateral reports: 24.9% and composite adherence score: 38.9%, respectively. The composite adherence score and collateral reports showed the highest and lowest sensitivities to NAH (72.1% and 15.8%, respectively). Specificity was highest for collateral reports of at least three clinicians (93.1%). Likelihood ratio of a positive test was 2.74 for composite adherence score. No measures showed high sensitivity alongside high specificity. Combining measures increased diagnostic accuracy, indicating the relevance of combined measures for clinical and research purposes.