Background
Methods
Data source and research strategy
Kidney transplantation | Keywords | Kidney transplantation, renal transplantation, kidney grafting, kidney transplant |
MeSH terms | Kidney transplantation | |
Self-management | Keywords | Self-care, disease management, self-management, decision aids, patient participation, patient involvement, medication alert system, reminder systems, patient education, patient empowerment, patient activation, patient engagement, patient participation, patient education, reminder systems, mobile health, telehealth |
MeSH terms | Self-care, disease management, reminder systems, patient participation, patient education, decision support techniques, clinical decision support systems, telemedicine |
Eligibility criteria
Data extraction
Risk of bias
Synthesis and analysis
-
Inform: Delivery media (e.g. text, voice, photo, and video).
-
Instruct: Offer instructions to the user
-
Record: Capture data entered by the user
-
Display: Show or output data entered by the user
-
Guide: Deliver guidance based on user provided information
-
Remind/Alert: Provide alerts and reminders for specific tasks or at specific times to the user
Results
Study selection
Bias risk assessment
The impact of interventions on outcome measures
Source, author, year, country | Participants | Sample Size (n) | Intervention | Duration | Outcomes | Results | Effect | Conclusion |
---|---|---|---|---|---|---|---|---|
Christina Freier et al., Germany [31] | Adolescents following transplantation | IG (26) CG (24) | Educational programme using the OTIS system (computer systems) | 24 months | (1) Process outcome (IRK and IRB) (2) Clinical outcome (GFR) | (1) Overall IRK improved significantly over time (p < 0.0001) for IGr patients relative to CGr. Analysis of IRK demonstrated a significant increase in knowledge from T0 to T1 (p < 0.028) and from T1 to T2 (p < 0.045) in the IGr when compared to the CGr. With respect to IRB (2) The GFR gradient was stable in the IGr relative to a significant decrease in the CGr (p < 0.001) | (1) Positive effect (2) No effect | The results presented this medium holds the potential to improve perceived IRK and behavior. Moreover, this medium can support the challenging transition period from pediatric to adult care |
Robinson et al., United States [36] | Kidney transplant recipient | IG (84) CG (86) | Educational tablet program (Smartphones/software) | 2 weeks | (1) Process outcome (knowledge) (2) Process outcome (Recognize personal skin cancer risk) (3) Process outcome [Willingness to change sun protection (20–100 scale)] (4) Process outcome (sun-protection use) (5) Process outcome (Daily hours outdoors (0.5–6 h) | (1) The increase in knowledge of Hispanic Latino kidney transplant recipients was significantly greater than the increase in knowledge by non-Hispanic white and non-ispanic black kidney transplant recipients (p < .05) (2) Recognize personal skin cancer risk (1–5 scale) (3) The greatest willingness to change sun protection was demonstrated by Hispanic Latino kidney transplant recipients (p < .05) (4) use of sun protection increased from baseline to 2 weeks after the program in participants from all ethnic/racial groups in comparison with controls (p < 0.05) (4) Daily hours outdoors [0.5–6 h (p value = 0.01)] | (1) Positive effect (2) Positive effect (3) Positive effect (4) Positive effect (5) Positive effect | Kidney transplant recipients from diverse racial/ethnic groups and health literacy levels who used SunProtect became aware of their risk of developing skin cancer, increased their knowledge of skin cancer and sun protection, showed willingness to change their sun rotection, and changed their sun-protection behavior. Educational program with a tablet computer during the kidney transplant recipients’ 6- or 12-month follow-up visits to the transplant nephrologist improved sun protection in all racial/ethnic groups. Tablets may be used to provide patient education and reduce the physician’s burden of educating and training patients |
McGillicuddy et al., United States [3] | Kidney transplant recipient | IG (11) CG (10) | mHealth system (include a BP monitoring device + electronic medication tray + a smart phone + text message) (Smartphones or PDA) | 3 months | (1) Process outcome (medication adherence) (2) Clinical outcome (systolic blood pressure) (3) Clinical outcome (diastolic blood pressure) | (1) The repeated-measures ANOVA yielded a significant group by time interaction F 3,48 = 11.74, p < 0.001, and a significant main effect for time F 3,48 = 32.81, p < 0.001, 2) (2) A significant group by time interaction was observed for systolic BP (SBP), F 3,51 = 4.33, p = .009 (3) Results for diastolic blood pressure (DBP) also revealed a significant group by time interaction F 3,51 = 4.58, p = 0.006 | (1) Positive effect (2) Positive effect (3) Positive effect | Prototype mHealth system was acceptable and resulted in significant improvements in medication adherence and BP control |
Gordon et al., United States [33] | Hispanic kidney transplant candidates and their family Members and friends | IG (61) CG(62) | Website (computer systems) | 3 weeks | Process outcome (knowledge about LDKT) | Website exposure was associated with a mean 21.7% same day knowledge score increase between pretest and posttest (p < 0.001). At 3 weeks, website participants' knowledge scores remained 22.6% above the pretest; control scores increased to 11.8% (p = 0.0001). Regression results found that website participants were associated with a 10.0% greater knowledge score at 3-week follow-up (p < 0.0001) | Positive effect | Our culturally targeted website increased participants' knowledge about LDKT (living donor kidney transplantations) above and beyond an in-person educational session in Spanish or English |
Gordon, United States [34] | Kidney transplant candidate | IG(133) CG(155 | Mobile Web application (Inform Me) (Smartphones/software) | 3 weeks | (1) Process outcome (Knowledge about increased risk donor Kidney) (2) Process outcome (Willingness to accept increased risk donor kidney) | (1) Intervention participants had higher test 1 knowledge scores (mean difference, 6.61; 95% confidence interval [95% CI], 5.37–7.86) than control participants, representing a 44% higher score than control participants' scores. Intervention participants' knowledge scores increased with educational reinforcement (test 2) compared with control arm test 1 scores (mean difference, 9.50; 95% CI, 8.27–10.73). After 1 week, intervention participants' knowledge remained greater than controls' knowledge (mean difference, 3.63; 95% CI, 2.49–4.78) (test 3) (2) Willingness to accept an increased risk donor kidney did not differ between study arms at tests 1 and 3 | (1) Positive effect (2) No effect | Inform Me use was associated with greater knowledge about increased risk donor kidneys above routine transplant education alone |
Reese, United States [35] | Kidney transplant recipients | IG1(40) IG2(40) CG(40) | Wireless pill bottles monitoring with customized reminders (including alarms, texts, telephone calls, and/or e-mails) (multi-component system) | 26 weeks | (1) Process outcome (bottle-measured tacrolimus adherence) (2) Clinical outcome (tacrolimus whole-blood concentrations) | (1) Mean adherence was 78%, 88%, and 55% in the reminders, reminders-plus-notification, and control arms (p, 0.001 for comparison of each intervention to control) (2) Mean tacrolimus levels were not significantly different between groups | (1) Positive effect (2) No effect | Provider notification and customized reminders appear promising in helping patients achieve better medication adherence, but these strategies require evaluation in trials powered to detect differences in clinical outcomes |
Schmid, Germany [22] | Renal transplant recipients | IG (23) CG (23) | Remote telemonitoring And Real-time video consultations with access to significant medical data (multi-component system) | 12 month | (1) Process outcome (Unplanned admission rate) (2) Process outcome (Length of unplanned stay) (3) Process outcome (Unplanned inpatient care costs) (4) Clinical outcome (acute Rejection rate) (5) Process outcome (rejection therapy initiation) (6) Clinical outcome [Estimated glomerular filtration rate (eGFR)] (7) Process outcome (Ambulatory care visit rate) (8) Process outcome (Immunosuppressive regimen Adherence) (9) Process outcome (Quality of life) (10) Process outcome (Return to employment) | (1) IG had significantly fewer unplanned admissions [IG (median = 0 admissions, interquartile range [IQR] = 1) versus CG (median = 2 admissions, IQR = 2)] (2) IG (median = 0 days, IQR = 6) versus CG (median = 13 days, IQR = 23) (3) The 23 RTR in the CG were hospitalized 29 times more often and spent 283 days longer in inpatient care, with correspondingly greater costs (4) The CG suffered two graft losses, the IG none (5) Biopsy-proven acute rejection rates were too low for permit comparative analyses (6) Both groups maintained transplant function: the median difference for the change in estimated GFR was + 3.6 mL in IG versus + 0.6 mL in CG (7) Differences in ambulatory care visit rates did not reach statistical significance (IG: median = 43 visits, IQR = 22. CG: median = 45 visits, IQR = 28) (8) The prevalence of nonadherence was 17.4% in the IG versus 56.5% in CG (p = 0.013) (9) The scores differed from the SOCG most significantly at T4 (IG [median = 0, IQR = 0.2] versus CG [median = 0.4, IQR = 0.6], p = 0.004, r = 0.42) (10) The IG returned to full employment soon after discharge, as indicated by their median working time percentages, which remained stable throughout year 1 post-transplant. The CG differed significantly between the baseline assessment (median = 50%, IQR = 100) and month 3 post-transplant (median = 0%, IQR = 50), Z = 2.694, p = 0.006, and did not return to full employment within the first post-transplant year | (1) Positive effect (2) Positive effect (3) Positive effect (4) No effect (5) No effect (6) No effect (7) No effect (8) Positive effect (9) Positive effect (10) Positive effect | This comparative effectiveness research has demonstrated the potential of telemedically supported case management to optimize routine evidence-based post-transplant aftercare and support its application at tertiary care hospitals. It provides a basis for a multicenter randomized trial to verify these outcomes in the medium and long term |
Côté et al., Canada [32] | Renal transplant recipients | IG (35) CG (35) | Interactive Web-based sessions hosted by a virtual nurse(computer systems) | 6 months | (1) Process outcome (Medication adherence) (2) Process outcome (Self-Efficacy) (3) Process outcome (skills) (4) Process outcome (medication side effects) (5) Process outcome (Self-Perceived General State of Health) | No statistically significant differences between the groups or over time (1) p value = 0.2 (2) p value = 0.37 (3) p value = 0.39 (4) p value = 0.44 (5) p value = 0.38 | (1) No effect (2) No effect (3) No effect (4) No effect (5) No effect | This study showed that the Transplant-TAVIE, a Web-based tailored nursing intervention, is acceptable and could constitute an accessible adjunct in support of existing specialized services. However, given that this treatment is life long, it is important to deploy interventions adapted to the different phases of the medication management continuum in order to support these patients more effectively |
Outcome category | Outcome | Total | Effect | Effective interventions | Ineffective interventions | |
---|---|---|---|---|---|---|
Positive effect N (%) | No effect N (%) | |||||
Clinical outcome (n = 6) | GFR | 2 | 2(100%) | Computer systems (1) Multi-component systems(1) | ||
Systolic blood pressure | 1 | 1(100) | Smartphones or PDA (1) | |||
Diastolic blood pressure | 1 | 1(100) | Smartphones or PDA (1) | |||
Tacrolimus whole-blood level | 1 | 1(100) | Multi-component systems(1) | |||
Acute Rejection rate | 1 | 1(100) | Multi-component systems(1) | |||
Process of care (n = 24) | IRB and IRK | 1 | 1(100) | Computer systems(1) | ||
Knowledge | 3 | 3(100) | Smartphones or PDA (2) Computer systems (1) | |||
Recognize personal skin cancer risk | 1 | 1(100) | Smartphones or PDA (1) | |||
Willingness to change sun protection | 1 | 1(100) | Smartphones or PDA(1) | |||
Sun-protection use | 1 | 1(100) | Smartphones or PDA(1) | |||
Daily hours outdoors | 1 | 1(100) | Smartphones or PDA(1) | |||
Medication adherence | 4 | 3(75) | 1(25) | Multi-component systems (2) Smartphones or PDA (1) | Computer systems(1) | |
Willingness to accept increased risk donor kidney | 1 | 1(100) | Smartphones or PDA(1) | |||
Unplanned admission rate | 1 | 1(100) | Multi-component systems(1) | |||
Length of unplanned stay | 1 | 1(100) | Multi-component systems(1) | |||
Unplanned inpatient care costs | 1 | 1(100) | Multi-component systems(1) | |||
Rejection therapy initiation | 1 | 1(100) | Multi-component systems(1) | |||
Ambulatory care visit rate | 1 | 1(100) | Multi-component systems(1) | |||
Quality of life | 1 | 1(100) | Multi-component systems(1) | |||
Return to employment | 1 | 1(100) | Multi-component systems(1) | |||
Self-Efficacy | 1 | 1(100) | Computer systems(1) | |||
skills | 1 | 1(100) | Computer systems(1) | |||
Medication side effects | 1 | 1(100) | Computer systems(1) | |||
Self-perceived General State of Health | 1 | 1(100) | Computer systems(1) | |||
Total | 31 | Clinical (2) Process (16) 18(60) | Clinical (4) Process (8) 12(40) | Computer systems (2) Multiple components (7) Smartphones or PDA(9) | Computer systems (6) Multiple components (5) Smartphones or PDA(1) |
Clinical outcomes
Care process outcomes
Interventions classification based on the type of technology and characteristics
References | Classification of consumer health informatics | Technology platform | Technology functionality | Technology description |
---|---|---|---|---|
Freier et al. [31] | Computer systems | Computer-based educational programme | Inform | A computer program was designed to arrange clinical information about pre-transplant, transplant operation, and post-transplant recommended care. The program also offered relevant medication taking behaviors based on each patient’s medication regimen. An interactive quiz was also obtained at the end of each education session to provide neutral feedback (correct or incorrect answer) |
Robinson et al. [36] | Smartphones or PDA | Tablet program | Inform Communicate | A tablet-based program was implemented to offer interactive recommendations about sunscreen behaviors (e.g. skin cancer, appropriate methods for getting sun exposure, protective clothing, and etc.). Personal concerns of patients were also discussed by a physician during a live chatting session |
McGillicuddy et al. [3] | Smartphones or PDA | A blood pressure monitoring device and electronic medication | Remind/Alert communicate | A smartphone connected to a wireless blood pressure monitoring device was used to record encrypted physiological parameters and also text messages reminders were sent to assist regular blood pressure monitoring process |
Gordon et al. [33] | Computer systems | Website | Inform Instruct communicate | A website was designed to present 5–10 interactive messages on each of the following items: risks of donation and its relevant immigrant, financial, and cultural issues as well as available treatment options. A link to detailed description of each subject was also provided for interested patients. Moreover, interactive multimedia contents (e.g. video, telenovela, photograph, quizzes, and games) were also offered |
Gordon et al. [34] | Smartphones or PDA | Mobile application | Inform Instruct | The iPad app, Inform Me used Computer Adaptive Learning (CAL) method to personalize educational materials and content according to each KTC comprehension levels in 5 interactive chapters: Introduction, Definition of Increased Risk, Risks and Benefits, Screening for Infection, and Treatment and Follow-Up. The Introduction provides an orientation and instructions; the other 4 chapters educate and assess comprehension. Inform Me shows videos, animations, and graphics to depict complex concepts |
Reese et al. [35] | Multiple component | Monitoring with customized reminders | Remind/Alert Record | An electronic adherence monitoring system including following features was provided to kidney transplant recipients: notifications on wireless pill bottle, phone calls playing recorded messages, and short text message or email reminders |
A. Schmid et al. [22] | Multiple component | Telemonitoring real-time video consultations | Record Display Remind/Alert Inform Instruct communicate | A telemonitoring system containing following features was implemented: (1) standard quiz including multiple-choice questions were obtained once a day, (2) self-measured data were transferred through a secure web-based connection, (3) clinical recommendations were provided via voice mailbox, phone calls, and short text messaging, (4) continuous access to a physician was provided to discuss possible daily concerns of the patients, (5) remote case management by resident nephrologists which was triggered in case of acute disorders |
José Côté et al. [32] | Computer systems (websites) | Transplant-TAVIE | Inform Instruct | Three interactive web-based sessions were design to improve patient’s self-efficacy by teaching medication intake behaviors as well as verbal persuasion. The web-site was built using 89 videos and animations, 58 PDF files, and 93 pages of educational content |
SUM | Computer systems (3studies) Multiple component (2 studies) Smartphones or PDA (3studies) |