Transplant Social Work and Directly Observed Therapy for Promotion of Medication Adherence in Adolescent Heart Transplant Recipients

Background and Purpose: Organ transplant social workers on multidisciplinary transplant teams address medication adherence and psychosocial factors related to poor health behaviors. Adherence with immunosuppressive medication remains a significant challenge for adolescent heart transplant (HT) recipients and an important predictor of poor posttransplant outcomes such as organ rejection, hospitalization, and mortality. Despite the high risk of non-adherence during adolescence, few interventions have been identified for use by transplant social workers which address multiple behavioral risk factors for non-adherence in this age group. This pilot study examined the acceptability and feasibility of an asynchronous video directly observed therapy (DOT) mHealth application among adolescent HT recipients.

Methods: Adolescent HT recipients were recruited to participate in a 12-week intervention focusing on a mobile DOT application by emocha Mobile Health Inc. Within the DOT application, patients self-record and submit videos while taking their medication, and these videos are later reviewed by transplant team members. The mobile application tracks of patients’ dose-by-dose medication adherence and offers video and text messaging between transplant team members and patients. Transplant social workers can interact with and engage with patients to offer encouragement, facilitate promotion of medication adherence, and address risk factors of poor adherence with adolescents. The primary outcome for this DOT pilot study was proportion of daily medication doses observed via video submission by transplant team members. Medication adherence was also assessed through medication level variability index values (MLVI), a biomedical indicator of medication assessed through routine blood levels. Self-report measures from patients and caregivers were used to assess changes in health-related quality of life and perceived adherence barriers from pre- to post-intervention time points. Long-term health outcomes included post-intervention instances of acute rejection and hospitalization 6 months following DOT.

Findings: Among 14 adolescent HT patients approached, 10 initiated the DOT intervention. Of these, 8 patients completed the 12-week intervention. Patients and caregivers reported high perceptions of acceptability and accessibility during initial 3-week acceptability interviews. Over 12 weeks, patients submitted 90.1% of possible videos demonstrating medication doses taken twice daily. Patient and transplant team members exchanged 909 in-application text messages including those encouraging patients, building rapport, and offering patients feedback about their progress. MLVI values (MLVI) for the 10 patients receiving at least three weeks of DOT decreased by 21.7% representing a clinically significant improvement in medication blood levels. Only one patient completing the 12-week DOT intervention experienced hospitalization unrelated to organ rejection, yet 83.3% of those patients dropping out (n=6) were hospitalized or experienced episodes of organ rejection in the 6 months following their participation (Fisher’s exact p=.026, ϕ=.708).

Conclusion and Implications: DOT appears to be supportive of promotion of medication adherence in adolescent HT recipients. Results point to the potential value of mobile health technology to health promotion in high-risk pediatric populations and of these approaches in health social work practice. Further research is required to assess ongoing acceptability and long-term outcomes.