© 2013 Direct One Communications, Inc. All rights reserved. 1 Improving Transplant Outcomes Through Teaching and Technology: Emerging Technologies Victoria

© 2013 Direct One Communications, Inc. All rights reserved. 1

Improving Transplant Outcomes Through Teaching and Technology: Emerging Technologies

Victoria L. Shieck, RN, BSN, CCTN

University of Michigan Health System Transplant Center, Ann Arbor, Michigan

A REPORT FROM THE 2013 AMERICAN TRANSPLANT CONGRESS


Literacy and Medication Adherence

Medication nonadherence is related to health literacy.1

An average of 39% of all 4th graders in the US scored “below proficient” in reading.2

Only 74% of 12th graders read at or above grade level.3

> 40 million adults in the US do not have the basic reading skills needed to fully function in society.4

50 million more Americans had mediocre reading skills.

Depressed literacy levels keep patients from taking an active role in their own healthcare decisions and treatment.5


Age, Literacy, and Adherence

The Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Mini Mental State Examination were used to study functional health literacy among community-dwelling older people.6

S-TOFHLA scores (range, 0–100) fell by an average of 1.4 points for every year increase in age.

» Not explained by differences in frequency of newspaper reading, visual acuity, health, or chronic medical conditions

Below-average literacy is more often seen among the elderly.

» Some senior citizens cannot even circle the appointment date on a checkout sheet.


Challenges of Illiteracy

The Test of Functional Health Literacy Assessment was used to link literacy and health outcomes among 979 emergency department patients taking part in the Literacy in Health Care study.7

Altogether, 958 patients had an electronic medical record for 1994 and 1995.

» 53% had adequate literacy, 13% had marginal functional health literacy, and 35% had inadequate literacy.

Patients with low literacy had worse health and higher hospitalization rates and healthcare expenditures when compared with adequately literate patients.


Maneuvering Through the System

Patients with limited reading skills cannot understand signs and registration forms and may make serious errors when taking medication.8

They tend to rely greatly on visual clues, oral explanations, and physical explanations to learn about medical issues.

They depend upon friends or family members to be surrogate readers.

They may be ashamed of their inability to process written materials and may hesitate discussing the problem with healthcare professionals.


Patient Education Reading Levels

Health literacy problems for patients and their families are complicated by:

» Educational materials written at an advanced reading level

» The technical vocabulary used by healthcare providers.

Average patient education materials are written at a 10th-grade reading level or higher, even though most adults read at an 8th- to 9th-grade level.4

This situation is worse when a patient’s primary language is not English.9 At two public hospitals, fair-to-poor health literacy was found among 35% of patients who spoke English and 62% of those who spoke Spanish.10


Patient Functioning and Adherence

Patients or family members may have to calculate medication changes, although they often cannot understand routine laboratory or procedure results or even oral instructions.

The average patient functions at about a 4th-grade level in regard to health information

Written or spoken healthcare instructions should target a 3rd-grade level.

Instructions should be kept simple.

Healthcare professionals should use visual, oral, and written materials when providing information.


Helping Patients to Help Themselves

Complicated transplant medication schedules can be difficult for patients and families to follow and can lead to nonadherence.11

Adherence to drug regimens extends beyond simple compliance with medication schedules.

Medication adherence also may involve such health behaviors as alcohol consumption, poor dietary control, lack of exercise, and smoking.11

Close attention to drug schedules is tremendously important.


MedActionPlan

MedActionPlan is an online program that allows a transplant nurse or coordinator to enter each drug’s name, dose, and frequency (usually beginning with immunosuppressants, antihypertensive agents, and antibiotics) into a patient’s medication plan.

The program provides a description and/or indication for each drug and, where available, a photograph of the pill.

A medication schedule and check-off sheet may then be printed out in the office for patients to use at home, school, or work.


Medication Stickers

Medication stickers placed next to the dosing schedule also may help adherence.

Patients who cannot read even at a 1st-grade level may benefit from colored stickers affixed to a medication sheet and on the medication bottle.

Many pharmacies place the same colored stickers on refill bottles upon request.


Syringe Printouts

Many hospitals and clinics distribute syringe printouts to patients. The nurse or coordinator writes the name of the medication and the dose at the top of the printout. The syringe drawing is then colored with the volume to be administered. Parents with literacy problems match the first letters of the names of the color-coded drugs to the syringe handout. The handouts are updated with each change in medication or dose.


Solving Literacy Problems in the Clinic

Treatment might be easier for illiterate patients if:

Written materials and spoken instructions were easily understood.

Words used to educate remained simple.

Different teaching methods were used for patients and families:

» Use the phrase “anti-rejection pills” instead of “immunosuppressants.”

» Reinforce oral instructions with visual aids and handouts for patients and their families.

» Repeat patient care instructions at every clinic visit.


Incorporating Technology

Following transplantation, adolescents have the highest incidence of medication nonadherence and potential graft loss among all age groups.

A main reason for the lack of adherence is that they are “too busy” to remember to take their medications or that they “just forgot.”

Clinical outcomes among adolescent transplant recipients may be improved if a texting strategy is used as a reminder system.


Using Texting as an Adherence Tool

Miloh and others12 designed a program using cell phone texting to help remind adolescent transplant recipients to take their medication on schedule.

Teens receive a text from their hospitals reminding them to take their medications.

After the drug is taken, the adolescents text back to the computers.

If the computers don’t receive a text within a certain period, the teens’ parents or guardians receive a phone call to remind the adolescents to take their immunosuppressant medications.


Using Texting as an Adherence Tool

Texting has effectively enhanced medication adherence.

Limitations:

» Not all families can afford a cell phone with texting ability.

» Not every hospital system is equipped or has the personnel to send out multiple texts to their patients or follow up via text or phone when patients don’t respond to the messages.

However, compared with the cost of treating a rejection episode and associated complications, using technology to reduce the incidence of nonadherence to immunosuppressants is priceless.


Evaluating Kidney Donors Via the Web

In years past, the average transplant coordinator spent long hours conducting telephone interviews with potential kidney donors.

An online kidney donor evaluation program was created to allow potential donors to add their own medical information into the system.13 » Potential donors can complete the online survey in

approximately 2½ minutes.

» Those meeting the minimal qualifications receive a call from a transplant coordinator by the next business day.

» If they do not meet the minimal qualifications, they receive an e-mail informing them why they are not potential candidates.


Success Through Technology

Altogether, 72% of potential kidney donors at the facility now are using this program.

» One reason for its success: Individuals can visit the website at times other than during average business hours.

Advantages include:

» Decreased cost for employee time on the telephone

» Immediate workup of potential donors who have already been screened

» Provision of immediate results to the potential donor and good data on all referrals to the transplant center


Success Through Technology

Future implications include:

» Availability of a recipient referral program

» Distribution of patient and family educational materials

» Maintenance of long-term follow-up with donors after transplant surgery is accomplished


Developing Apps to Improve Outcomes

Almost no available app is targeted to the needs of transplant physicians, nurses, or nurse coordinators.

» Even fewer are intended to assist in the care of transplant recipients.

Barriers to developing a smartphone or tablet app for the transplant community and patients are:

» Compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996

» The proprietary structure of the phones’ and tablets’ operating systems

» The small market needs for specific apps


Apps for Transplant Professionals

Tools for calculating a Kidney, Pancreas, or Liver Donor Risk Index to estimate the risk of graft failure post transplant

A Model for End-Stage Liver Disease (MELD) calculator

The Hepatocellular Carcinoma MELD Exception app (http://transplanttools.com)

Mobile Transplant Professional, an app for sharing and relaying news among healthcare professionals in the transplant community and facilitating collaboration on specific issues


App Problems and Solutions

Limitations include possible calculation errors and inaccuracy.

No FDA oversight or peer review is needed for their sale, use, or distribution.

Ideally, transplant apps should:» Supply a focused solution to a given problem (eg,

calculating a MELD score)

» Allow access to patient data and non-HIPAA data entry

» Provide patient education; examples: • Augmented Reality Liver Viewer

• Care After Kidney Transplant, developed by the National Kidney Foundation and available only for the iPhone and iPad


Conclusion

Short- and long-term complications related to organ transplant may be reduced by:

» Changing patient and family education processes

» Keeping reading materials at an elementary-school level of understanding

New technology that includes texting, apps, and Web-based programs can enhance patient care and adherence to medication.

Future technologic strides will transform medical practice and, likewise, organ transplantation as we know it.


References1. Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to

intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27:173–178.

2. National Center for Education Statistics. The Nation’s Report Card: Reading 2011. (NCES 2012–457). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, US Department of Education; 2011. http://nces.ed.gov/nationsreportcard/pdf/main2011/2012457.pdf. Accessed June 11, 2013.

3. National Center for Education Statistics. The Nation’s Report Card: Reading 2009 (NCES 2010–458). Washington, DC: Institute of Education Sciences, US Department of Education, National Center for Education Statistics; 2010. http://nationsreportcard.gov/reading_2009/. Accessed June 11, 2013.

4. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: US Department of Education, National Center for Education Statistics; 1993.

5. Miles S, Davis T. Patients who can’t read: implications for the health care system. JAMA. 1995;274:1719–1720.

6. Baker DW, Gazmararian JA, Sudano J, Patterson M. The association between age and health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci. 2000;55:S368–S374.

7. Baker DW, Parker RM, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13:791–798.

8. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329–334.

9. Nielsen-Bohlman L, Panzer AM, Hamlin B, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: Institute of Medicine; April 2004. http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx. Accessed June 11, 2013.


References10. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among

patients at two public hospitals. JAMA. 1995;274:1677–1682.

11. Fine RN, Becker Y, De Geest S, et al. Meeting report: nonadherence consensus conference summary report. Am J Transplant. 2009;2:35–41.

12. Miloh T. Text4Health: texting as a strategy to improve outcomes post-transplant. Presented at the 2013 American Transplant Congress; May 18–22, 2013; Seattle, Washington. Abstract MD06b.

13. Moore D. Emerging technologies in transplantation: web. Presented at the 2013 American Transplant Congress; May 18–22, 2013; Seattle, Washington. Abstract B1018.

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© 2013 Direct One Communications, Inc. All rights reserved. 1 Improving Transplant Outcomes Through Teaching and Technology: Emerging Technologies Victoria