title: Adherence in pediatric kidney transplant recipients: solutions for the system.
abstract: Non-adherence remains a significant problem among pediatric (and adult) renal transplant recipients. Non-adherence among solid organ transplant recipients results in US$15-100 million annual costs. Estimates of non-adherence range from 30 to 70% among pediatric patients. Research demonstrates that a 10% decrement in adherence is associated with 8% higher hazard of graft failure and mortality. Focus has begun to shift from patient factors that impact adherence to the contributing healthcare and systems factors. The purpose of this review is to describe problems within the systems implicated in non-adherence and potential solutions that may be related to positive adherence outcomes. Systems issues include insurance and legal regulations, provider and care team barriers to optimal care, and difficulties with transitioning to adult care. Potential solutions include recognition of how systems can work together to improve patient outcomes through improvements in insurance programs, a multi-disciplinary care team approach, evidence-based medical management, pharmacy-based applications and interventions to simplify medication regimens, improved transition protocols, and telehealth/technology-based multi-component interventions. However, there remains a significant lack of reliability in the application of these potential solutions to systems issues that impact patient adherence. Future efforts should accordingly focus on these efforts, likely by leveraging quality improvement and related principles, and on the investigation of the efficacy of these interventions to improve adherence and graft outcomes.
authors.affiliation: Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA. Elizabeth.Steinberg@ucdenver.edu.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Steinberg
authors.affiliation: Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Moss
authors.affiliation: Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA.|Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Buchanan
authors.affiliation: Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Jens
authors.initials: J
authors.lastname: Goebel
mesh_terms: D000293:Adolescent; D002648:Child; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000191:economics; D016030:Kidney Transplantation / Q000009:adverse effects*; D010349:Patient Compliance / Q000706:statistics & numerical data*; D012307:Risk Factors; D066027:Transplant Recipients / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D007166:Immunosuppressive Agents
keywords: Adherence; Healthcare system; Immunosuppression; Kidney transplant; Pediatric; Quality improvement