Medication adherence in pediatric and adolescent liver transplant recipients.
OBJECTIVE
Nonadherence to medications is a leading cause of morbidity in children and adolescents who have had a transplant, yet there are no published data about the use of different methods for detecting whether these children are taking their medications. There are also no published data about the age of transition at which a child assumes responsibility over taking the medications. This information is important if interventions to improve adherence are contemplated.


METHODS
We present an analysis of data obtained in the first year of the implementation of an adherence assessment protocol at a pediatric liver transplant clinic in a tertiary medical care center. Data were obtained for children and adolescents who had a liver transplant at least 1 year before the assessments took place. We used 5 adherence detection methods. The 4 subjective methods were self-reported, scaled questionnaires answered by nurses, physicians, caregivers, and patients. For the objective method, a standard deviation (SD) was calculated for tacrolimus blood levels obtained from each patient over time. A higher SD suggests increased variation among patients' blood levels and hence more erratic medication taking. We also asked the patients and caregivers who is responsible for taking the medications and what are the reasons for not taking them. The medical outcome measures were biopsy-proven rejection episodes, number of biopsies regardless of the results, number of hospital admissions, and number of in-patient days.


RESULTS
An analysis of 81 cases (258 assessments) revealed that the only method that predicted the medical outcome variables (biopsy-proven rejection and number of biopsies) was the SD of medication blood levels. Patients', clinicians', and caregivers' reports were not predictive. Clinicians' ratings of adherence were not correlated with patients' or caregivers'. The transition of responsibility for medication taking occurred approximately at the age of 12 years. Forgetfulness was cited as the most common reason for nonadherence by patients and caregivers; medication side effects were not frequently cited.


CONCLUSIONS
Our results indicate that clinical impression is not sufficient to determine whether children and adolescents are taking their medications after they have had a liver transplant. An objective assessment method should be used. Interventions targeting adherence should address the child's increasing role beginning in early adolescence. A clinical protocol incorporating objective assessments of adherence could potentially be implemented in other settings. It could form the basis for the evaluation of efficacy of interventions seeking to improve adherence to medications.
Shemesh
Eyal
E
Department of Pediatrics, Mount Sinai Medical Center, New York, New York 10029, USA. eyal.shemesh@mssm.edu
Shneider
Benjamin L
BL
Savitzky
Jill K
JK
Arnott
Lindsay
L
Gondolesi
Gabriel E
GE
Krieger
Nancy R
NR
Kerkar
Nanda
N
Magid
Margret S
MS
Stuber
Margaret L
ML
Schmeidler
James
J
Yehuda
Rachel
R
Emre
Sukru
S
D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000367:Age Factors; D017028:Caregivers; D002648:Child; D002675:Child, Preschool; D006084:Graft Rejection / Q000473:pathology; D006801:Humans; D007166:Immunosuppressive Agents / Q000097:blood / Q000627:therapeutic use*; D008099:Liver / Q000473:pathology; D016031:Liver Transplantation; D010349:Patient Compliance; D012646:Self Administration; D011795:Surveys and Questionnaires; D016559:Tacrolimus / Q000097:blood / Q000627:therapeutic use*; D016312:Treatment Refusal
D007166:Immunosuppressive Agents; D016559:Tacrolimus