A systematic review of immunosuppressant adherence interventions in transplant recipients: Decoding the streetlight effect

Abstract

Non-adherence to immunosuppressant medications is an important risk factor for graft dysfunction. To evaluate the effectiveness of adherence-enhancing interventions, we reviewed adherence intervention studies in solid organ transplant recipients (all ages). Using the following databases: PsycINFO, PubMed, Scopus, and ScienceDirect, we identified 41 eligible studies. Only three non-randomized trials showed a possible positive effect on objective indicators of transplant outcomes (such as rejection, liver enzyme levels, kidney function). None of the 21 RCTs showed an improvement in transplant outcomes. Three studies showed a higher rate of adverse events in the intervention group as compared with controls, although this may be related to ascertainment bias. Improvement in adherence as measured indirectly (eg, with electronic monitoring devices) was not aligned with effects on transplant outcomes. We conclude that adherence interventions, to date, have largely been ineffective in improving transplant outcomes. To improve this track record, intervention efforts may wish to concentrate on non-adherent patients (rather than use convenience sampling, which excludes many of the patients who need the intervention), use direct measures of adherence to guide the interventions, and employ strategies that are intensive and yet engaging enough to ensure that non-adherent patients are able to participate.

Adherence to Medication During Transition to Adult Services

“…A critical component of assessing and addressing adherence in both clinical and research settings is the use of accurate, objective adherence measures [12]. Self-reported adherence does not always translate into actual adherence.…”

Comparison of a home-based (multi) systemic intervention to promoting Medication AdheRence and Self-management among kidney transplant recipients with care-as-usual: the MARS randomized controlled trial protocol

“…Developing interventions that target non-adherence and suboptimal self-management has been suggested to be one way to optimize clinical outcomes [1]. However, interventions effective in promoting adherence and selfmanagement are scarce [20][21][22]. In the current literature there are two main explanations for the lack of effects: limitations of the interventions; and limitations of the research methods.…”

“…Secondly, there are methodological shortcomings of the research conducted to test the effectiveness of interventions in changing clinical outcomes. In their review, Duncan et al [22] highlighted 'the streetlight effect' whereby studies assessing adherence promoting interventions make one or both of the following errors:…”

“…"the research is being conducted on the wrong set of patients (the researchers focus on a sample that is easiest to recruit but is not representative of the population that is supposed to be treated); or the intervention examines the wrong set of outcome measures (typically, this means studies that use process measuresmeasures that look at some aspect of the intervention's purported mechanism of action but not at the actual outcomes)" [22].…”

“…To avoid the streetlight effect and therefore increase chances of finding an effect on adherence and transplant outcomes they recommended avoiding the use of convenience samples [22]. This should be avoided as you cannot demonstrate an effect of the intervention among patients who are already adherent.…”