Telemedically Supported Case Management of Living-Donor Renal Transplant Recipients to Optimize Routine Evidence-Based Aftercare: A Single-Center Randomized Controlled Trial

Abstract

Improving mid-term and long-term outcomes after solid organ transplantation is imperative, and requires both state-of-the-art transplant surgery and optimization of routine, evidence-based aftercare. This randomized, controlled trial assessed the effectiveness of standard aftercare versus telemedically supported case management, an innovative aftercare model, in 46 living-donor renal transplant recipients during the first posttransplant year. The model includes three components: (i) chronic care case management initiated after discharge, (ii) case management initiated in emerging acute care situations, and (iii) a telemedically equipped team comprising a transplant nurse case manager and two senior transplant physicians (nephrologist, surgeon). Analyses revealed a reduction of unplanned inpatient acute care, with considerable cost reductions, in the intervention group. The prevalence of nonadherence over the 1-year study period was 17.4% in the intervention group versus 56.5% in the standard aftercare group (p = 0.013). Only the intervention group achieved their pre-agreed levels of adherence, disease-specific quality of life, and return to employment. This comparative effectiveness study provides the basis for multicenter study testing of telemedically supported case management with the aim of optimizing posttransplant aftercare. The trial was registered with the German Clinical Trials Register (www.DRKS.de), DKRS00007634.

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

“…Studies were conducted in liver (n = 8), kidney (n = 25), heart or heart/lung (n = 2), and lung transplant recipients (n = 4), as well as mixed groups (n = 2). Of the RCTs, 11 did not report on transplant outcomes, and 10 examined them and found no effect of the intervention . Table is a detailed review of the 10 RCTs that looked at transplant outcomes (and found no intervention effect); this table also presents other outcomes that were examined in those studies.…”

“…Intervention strategies that are likely to improve transplant outcomes in non‐adherent patients probably have to be more comprehensive than simple reminders or automated strategies, yet also unobtrusive enough to avoid posing an excessive burden on patients. A promising example involves the use of intensive case management delivered via a telemedicine paradigm …”

Heart transplant centers with multidisciplinary team show a higher level of chronic illness management – Findings from the International BRIGHT Study

“…length of unplanned hospital stay compared to those in the standard care group. 13 This study has several limitations. First, given that this was a secondary analysis of existing data, it is unclear whether the presence of other factors not assessed in this study confounded the significant association between multidisciplinarity and level of CIM.…”

“…12 In transplantation, the reengineering of transplant follow-up care according to the principles of CIM has resulted in improved clinical outcomes, reduced health care utilization, and reduced costs. 10,13 In the most recent guidelines for the care of HTx recipients, the International Society of Heart and Lung Transplantation (ISHLT) recommended that transplant centers utilize a multidisciplinary approach to patient management. 6 This recommendation is similar to the Centers for Medicare and Medicaid policy that specifies that a multidisciplinary team should be involved in the care of transplant recipients throughout all phases of the transplantation.…”

Improving medication adherence: The proof of the pudding will be in the eating

“…Convincing evidence from other chronic illnesses like heart failure or diabetes shows that better management results in improved outcomes . Two renal transplant programs found better adherence and fewer emergency visits and hospital readmissions in patients exposed to a transplant follow‐up model based on the principles of chronic illness management …”