The increasing prevalence of end-stage kidney disease, the shortage of kidney donors, and the economic and health-related benefits of kidney transplantation make the prevention of adverse outcomes following transplantation a healthcare imperative (Khan & Amedia 2008). Medicine adherence in kidney transplantation is critical to the success of the graft (Pinksy et al. 2009). Interventions are needed to help kidney transplant patients take all their medications as prescribed. The purpose of this study was to establish what usual care entails for adult patients who received either a live or deceased kidney transplant at all five tertiary hospitals offering adult kidney transplantation in Victoria, Australia in preparation for testing an intervention designed to improve medicine adherence in this cohort. Approximately 230 kidney transplants are performed in Victoria annually.
Renal nurse transplant coordinators were interviewed face-to-face by two investigators who took hand written notes. The structured interview schedule consisted of 12 questions, such as, ‘If a patient is receiving a kidney transplant from a live donor, what occurs prior to the operation?, ‘How does this differ from a deceased donor?’ and ‘If a patient was found to be non-adherent to their medications, what actions would you take?’. Renal pharmacists were interviewed by telephone regarding their role in preparing patients to take their medications as prescribed. The structured interview schedule consisted of 12 questions focussing on patient education and methods to enhance medicine adherence. Examples of questions included, ‘Are you aware of patients using a Dosette box? If so, when is the Dosette box introduced post-transplantation?’, and ‘How do you ensure that the patient has adequate prescriptions for their medications?’. Notes were sent back to each renal transplant coordinator and pharmacist as a method of verification. All data underwent Sandelowski’s (2000) method of descriptive analysis.
Nine renal nurse coordinators participated in face-to-face interviews lasting approximately one hour and five renal pharmacists were interviewed for approximately 15 minutes by telephone. Although usual care differed between sites, there were similarities in approaches to facilitate medicine adherence. These included pre-transplant education sessions which included medications used to treat rejection, the use of medication aids such as Dosette boxes and Webster packs, and ensuring adequate medication supplies. It was more difficult to ensure recipients of deceased kidney transplants had received adequate preparation for their kidney transplant due to the urgency of the surgery. However, each site had developed their own way of educating the patient about their medications delivered by certain health professionals. Generally, pharmacists took the main responsibility for educating patients about their medications post-transplantation prior to discharge and registered nurses reiterated this information every time the patient took their medications in hospital. Post-discharge, renal nurse transplant coordinators followed up long term medicine adherence that was monitored by medical staff through laboratory investigations. Overall, there was no standard approach to education regarding medications or the printed material given to the patient or the use of dose medication aids to facilitate medicine adherence.
Differences in usual care at the sites and a lack of standardised approaches to promoting medicine adherence have implications for evidence-based health care that maximises kidney transplant outcomes. Differences in usual care also have implications for the testing of an intervention designed to improve medicine adherence in a randomised controlled trial. Details of usual care is necessary with regard to minimise the risk of study-induced behavioural change (Smelt et al. 2010), and to ensure quality reporting of randomised controlled trials, the gold standard for evaluating interventions because of their ability to reduce bias (Moher et al. 2010).