Adherence Assessment During Transplant Social Work Services in Pediatric Heart and Lung Organ Transplantation

Background and Purpose: Social workers on multidisciplinary solid organ transplant teams play a critical role in the transplant process when providing services to transplant patients and their families. A vital aspect of this care is the assessment and promotion of immunosuppressant medication. The present study examines the use of calculating standard deviation scores of patient blood tests, a more recently developed measure of medication adherence. Social workers on these teams must be able to determine a patient’s adherence, and the statistical calculation using blood tests allows for detection of variability in medication levels.

Methods: The study used agency-generated data and medical records information to assess two measures of medication adherence. Data generated from the United Network of Organ Sharing (UNOS; Department of Health and Human Services) offered medical information and patient and family demographics. The posttransplant data included patients’ long-term health, medical outcomes, and adherence to medications. Medication adherence was measured using the posttransplant opinion of the physician and standard deviation (SD) scores of patients’ immunosuppressive medication, Tacrolimus (FK-506), blood levels. A recently proposed determination of medication non-adherence is a patient standard deviation score over 3.0.

Results: Data was collected on 105 pediatric heart and lung transplant recipients and their families. The children were predominantly male (57%), white (65%), and heart transplant recipients (78%) with a mean age at transplant of 10.1 years (sd=6.0). A majority of the parents had an educational level below a four-year college degree (70%), were from two-parent or blended family homes (64%), and had public insurance (70%).

The SD scores for individual’s blood levels had a mean of 4.29 (sd=1.79). Using the SD cut-off score of 3.0 as evidence of non-adherence, 79.6% of the sample was rated as being non-adherent according to the measure. These levels of non-adherence and blood level SD scores significantly differ from other studies reporting similar measurement. From the UNOS data, the physician reported 34.1% of the sample exhibited some evidence of medication non-adherence to an extent where their recovery was compromised. The mean SD scores for the group of patients rated as adherent by the physician (mean of 3.99, sd=1.55) and the mean of the non-adherent group (mean of 4.82, sd=1.70) significantly differed (t=2.18, df=77, p<.033). The SD scores and physician opinion of adherence predicted whether the patient received treatment for organ rejection and were associated with the number of rejection episodes experienced during the posttransplant period.

Conclusions: The two measures of adherence, blood level SD scores and the opinion of the physician, produced varied estimations of the medication adherence in the sample. With their association with medical outcomes, both measures offer assessments of patient adherence and offer avenues for patient and caregiver education surrounding consistency of medication use. The mission of transplant social workers is to maximize and extend quality of life for these pediatric transplant patients while promoting adherence to this life extending medication. Immunosuppressant medication SD scores may offer an additional assessment tool for use in social work clinical practice with transplant patients and their families.