Compliancy
Following a succesful lung transplant, all patients face known medical risks of rejection or infection. When patients do not comply with the prescribed postoperative medical regimen, they are at an increased risk for an irreversible rejection episode or rejection, which may result in death and meaningless loss of the donor organ. In a study of compliance in the first year after heart transplant, it was found that 37% of the patients were noncompliant with exercise, 34% were noncompliant in monitoring blood pressure, and 20% were noncompliant with medications. They also found that compliancy worsened with time.
Social support has repeatedly been found to enhance the medical and functional outcome of a variety of nontransplant clinical situations and research suggests that social support may be an important component of compliance in transplant recipients.
Another psychological factor which appears to have a positive impact on patients' compliance is health locus of control, which refers to the extent of an individual's perception of the control he or she has over health outcomes.
Method of Study - After institutional review board approved and informed consent, 18 female and 13 male patients, all whom had had lung transplants an average of 24 months earlier, participated in this study. All subjects were patients who either single or double lung transplants. A self-report compliance questionnaire consisted of 10 statements assessing postoperative compliance in the following areas: taking daily medication, weighing daily, taking temperature, blood pressure, and spirometer readings daily; making daily diary entries, exercising regularly, having laboratory test taken within 2 days of request by the transplant coordinator, having a formal pulmonary function test done every 3 months; and keeping clinic appointments.
Results - Of the 50 patients who had had transplants at the time of the study, 31 whose lung transplants had occurred an average of 24 months earlier participated. The majority (97%) of the patients were white; 3% were black. Patients ranged in age from 15-59 years (mean age, 33). Thirteen (42%) patients were single or never married, 14(45%) were married (mean length of marriage, 14 years), and 4 (13%) were divorced. Number of children ranged from 0 to 3 (mean,.42). Patient's educational levels ranged from 8 to 19 years (mean, 14)
Pre Transplant Factors - With regard to diagnosis, 74% of the patients had CF, 6% had chronic obstructive pulmonary disease, 10% had pulmonary fibrosis, and 10% were diagnosed with other lung diseases, including primary pulmonary hypertension, and interstitial pulmonary fibrosis.
Compliance Information Obtained from the Demographic Questionnaire
Medications -When asked how often in a month they forgot to take their medications, responses ranged from 0 to 2 times a month, with a mean of 0.26 times. 77.5% of patients reported that they did not forget to take their medication.
Spirometer - Patients are instructed to use their spirometer once each day and record the results daily in their diary. The number of times per week that patients reported using their spirometer ranged from 0 to 10 ( mean, 6.3), indicating that most patients were in compliance with this segment of their follow up care.Before and after transplant, patients are told to contact the coordinator if their spirometer reading decreases by 10%. Ninety-seven percent of the patients reported that they would contact the transplant coordinator if their spirometer reading decreased by 10% from the previous reading. The correlation between the number of time per week patients used their spirometer and the number of months since transplant. Patients who had recieved their transplants more recently used their spirometer more frequently. Also revealed was that CF patients used their spirometer more often than did patients with other lung diseases. This greater use may be because CF patients have been monitoring their lung function and their health for more years than patients with other lung diseases and thus are more diligent in using their spirometer.
Time spent in sun - Although post transplant patients are instructed to stay out of the sun or wear a sunscreen when they are outside because of an increased risk for skin cancer after transplant, 71% of the patients reported that they spent time in the sun. Of those individuals, the time spent in the sun ranged from 0 to 20 hours per week. Seven patients reported not wearing sunscreen. Strength of sunscreen used was negatively correlated with age - younger patients used sunscreens with higher SPF.
Appointments - Of the 31 patients, 22 indicated that they did not cancel their doctor appointments.
Fever - Correlation revealed a significant relationship between the number of months since transplant and the number of days it took patients to notify the coordinator following fever onset.
(Source - Progress in Transplantation, June 2000)
Compliance, Adherence and Choices
Compliance to certain people means doing exactly what someone tells them to do. The word often carries a rather harsh or judgemental tone, depending on the situation in which it is used and by the tone of voice of the person saying it. Sometimes we feel that the health care team, our family and friends are watching every move we make.To many people adherence and compliance mean the same thing. Literall, the words have the same meaning. However, adherence seems to have a softer, less judgemental tone to it.
Adherence seems to imply that the people who surround us have laid out the way they think we should act in a certain situation, then watched to see if we do the right thing for ourselves. As we get further down the road with our transplant, many individuals start to vary from the norm. It's easy to see why.We start to feel much better and can do so many things than we did prior to transplant.
Choice - The process of varying from the norm is where some of us learn about choices. There are several kinds of choices. On the spot decisions, except in a medical emergency are usually not the best decisions. Our health care can be very complicated and many aspects need to be considered and many aspects need to be considered when making major decisions. Informed choices are the goal. Patients can get a great sense of control over their own life by making their own choices. Making choices is not for everyone. Many people don't feel they are capable of getting very involved in their medical care. Others don't want to be in a position of responsibility for themselves. It has been my observation that well informed people handle adversity much better and feel more in control of their life than people wh have not taken the opportunity to explore their options and make their own choices. (Source: Transplant Chronicles)
Noncompliance with immunosuppressive medications in pediatric and adolescent patients receiving solid-organ transplants
The results from many studies have shown that the long-term allograft survival is least successful in adolescent recipients. The major cause of
late graft failure in adolescents can be contributed in large measure to medication noncompliance. Medication noncompliance in teenagers has been shown to be more than four times greater in adolescents than in adults. The cognitive skills and intellectual maturation of adolescents are still limited, and this is particularly true i adolescents with chronic diseases. They have difficulty with abstract thinking, particularly the conceptualization of future consequences of present actions. This leads to characteristic risk-taking behaviors, including noncompliance with medical treatments. This transition is more intricate for adolescents with chronic illness because of their physical limitations. There are a
number of strategies that are helpful in mitigating noncompliance. Adolescents must be dealt with directly. Previous noncompliant behaviors need to be acknowledged and dealt with, because studies show that noncompliance is a stable personality attribute that persists over time. Efforts should be made to choose medications that have the least side effects. Psychological and psychiatric conditions such as posttraumatic stress disorder require early recognition, diagnosis, and treatment. It is necessary to build rapport with teenagers, and this should start before transplantation. A multidisciplinary approach with physicians, social workers, nurses, and transplant coordinators is an effective mean of enhancing compliance. These and other strategies outlined in this discussion will enable the adolescent to achieve good compliance rates and prevent graft loss.
Noncompliance with immunosuppressive medications in pediatric and adolescent patients receiving solid-organ transplants (ADDED 9/21/04)
The results from many studies have shown that the long-term allograft survival is least successful in adolescent recipients. The major cause of late graft failure in adolescents can be contributed in large measure to medication noncompliance. Medication noncompliance in teenagers has been shown to be more than four times greater in adolescents than in adults. The cognitive skills and intellectual maturation of adolescents are still limited, and this is particularly true i adolescents with chronic diseases. They have difficulty with abstract thinking, particularly the conceptualization of future consequences of present actions. This leads to characteristic risk-taking behaviors, including noncompliance with medical treatments. This transition is more intricate for adolescents with chronic illness because of their physical limitations. There are a
number of strategies that are helpful in mitigating noncompliance. Adolescents must be dealt with directly. Previous noncompliant behaviors need to be acknowledged and dealt with, because studies show that noncompliance is a stable personality attribute that persists over time. Efforts should be made to choose medications that have the least side effects. Psychological and psychiatric conditions such as posttraumatic stress disorder require early recognition, diagnosis, and treatment. It is necessary to build rapport with teenagers, and this should start before transplantation. A multidisciplinary approach with physicians, social workers, nurses, and transplant coordinators is an effective mean of enhancing compliance. These and other strategies outlined in this discussion will enable the adolescent to achieve good compliance rates and prevent graft loss.(Source: Transplantation: 15 March 2004)
