Adherence management in transplantation

Abstract Medication adherence is a process consisting of three phases: initiation, implementation, and persistence. Nonadherence to immunosuppressive medications is substantial and increases over time after transplantation. Nonadherence to comedication is typically higher than to immunosuppressants. Nonadherence to immunosuppressants is associated with increased risks of poor clinical and economic outcomes. Minimal deviations from the prescribed immunosuppressive regimen (> 5%) are associated with a higher risk of poor clinical outcomes. The choice of a medication adherence measure should be based on the phase of adherence (initiation, implementation, and persistence), the context, its purpose (observational/interventional), the richness and reliability of data needed, and patients’ preferences and usability of the measures. Electronic monitoring provides the most reliable and richest data to date, but is not yet routinely implemented in transplant care. It is advised to combine measurement methods (e.g., therapeutic drug monitoring and a validated self-report questionnaire) to detect medication nonadherence. An ecological perspective is needed to assess determinants of medication adherence in transplantation. Recent research into determinants of medication adherence indicates that factors at higher levels of the health care system play a role in patients’ medication taking behavior. Nonadherence-enhancing interventions should address determinants at these higher levels through development of environments conducive for intervention at different levels. Congruent with prevailing policy recommendations, transplant health care professionals should receive training to manage adherence effectively, and adherence measurement and management should become an integral part of routine posttransplant care. This includes a regular assessment of patients’ medication intake behavior and barriers to adherence, so that tailored solutions can be discussed that go beyond providing patient education. Mapping relevant structural characteristics and practice patterns related to medication adherence management sheds light on little-known aspects of transplant management. The limited evidence indicates that some level of medication adherence management has been implemented as a near-universal feature of transplant care, yet further improvements should be based on evidence from transplant medication adherence trials. Chronic care models could provide fertile soil for redesigning follow-up care after organ transplant, thereby facilitating implementation of medication adherence management programs. Chronic care models show improved outcomes in view both of increased medication adherence and of reduced health care utilization in transplantation, and are linked with better clinical outcomes in other chronically ill patient populations. Therefore adoption of chronic care model principles could also improve long-term transplant outcomes. Translating the research evidence on state-of-the-art medication adherence management embedded in a chronic care model from the trial to real-world clinical settings will need investment in implementation science methodology. Only through partnerships of all stakeholders can this translation and thus optimization of transplant follow-up care successfully be achieved.