Transplant Regimen Adherence for Kidney Recipients by Engaging Information Technologies: The TAKE IT Trial

The investigators will evaluate a technology-enabled strategy designed to promote medication
adherence, routinely monitor regimen use, and mobilize appropriate transplant center
resources to respond early to kidney transplant recipients demonstrating inadequate
adherence.

Among patients receiving a kidney transplant (KT), the 5-year risk of organ (graft) failure
is high; 30% for deceased donor and 27% for living donor recipients. Medication non-adherence
is a leading root cause of graft failure, and KT recipients have the highest reported rate of
poor adherence (~35%) among all organ transplant recipients. Despite many attempts, there
have been few successful interventions evaluated to date that have significantly improved KT
recipients' regimen adherence and subsequent health outcomes over time.

There are many reasons why individuals may not take medication regimens as prescribed,
including but not limited to: forgetfulness, misunderstanding, regimen complexity, side
effects, health issues, social support, motivation and cost. Therefore no single solution can
address all patients. A healthcare team must understand the precise nature of a patient's
adherence barriers in order to properly respond. Yet medication adherence is not clinically
assessed as part of routine post-transplant care, and prior studies have found that medical
staff cannot readily identify poor adherence among patients, let alone the reasons why. Using
evidence from the research team's extensive previous studies in other chronic disease
contexts, the investigators will implement and comprehensively test a potentially low cost,
'low touch', thus highly scalable intervention: the Transplant regimen Adherence for Kidney
recipients by Engaging Information Technologies (TAKE IT) strategy.

The TAKE IT strategy leverages a transplant center's electronic health record and a web-based
patient portal, as well as mobile technology to: 1) educate patients on their prescribed Rx
regimens, 2) help them organize their daily regimen schedule in the most efficient manner, 3)
remind them via SMS (Short Message Service) text when to take their medicine, 4) routinely
monitor regimen use, and 5) provide care alerts to engage appropriate transplant center
clinical staff (e.g. nurse coordinator, pharmacist, social worker) when medication concerns
are detected. All components of the TAKE IT strategy have been developed with prior NIH
support, refined with 'user' input (patient, family, clinic staff), and their efficacy tested
in non-transplant settings.

The research team's primary aim and hypotheses (H) are to:

Aim 1 Test the effectiveness of the TAKE IT strategy, compared to usual care, to improve KT
recipients':

H1 treatment knowledge (indications, potential side effects, demonstrated proper use) H2
medication use (regimen adherence via self-report, pill count, pharmacy records, tacrolimus
levels) H3 transplant-specific outcomes (Δ eGFR (estimated glomerular filtration rate),
quality of life, re-hospitalization) H4 chronic disease outcomes (blood pressure, HbA1c) They
will conduct a 2-arm, patient-randomized controlled trial at two large, diverse transplant
centers (Northwestern University; Mayo Clinic). 300 KT recipients within 3 months of
transplant ('de novo') and 400 'established' patients between 18 months and 3 years post-KT
will be recruited and followed for 2 years (N=700 patients; n=350 per site and n=175 per
study arm within each site). In-person interviews will be conducted at baseline, 6, 12, 18
and 24 months. To determine proximal effects of the TAKE IT strategy, a telephone interview
will also be administered 6 weeks post-baseline. Electronic health and pharmacy records will
be ascertained to capture medication adherence and clinical outcomes.

The secondary aims are to:

Aim 2 Examine the persistence of any effects of the TAKE IT strategy on outcomes over 2 years
among new and established KT recipients.

Aim 3 Evaluate the fidelity of each component of the TAKE IT strategy over time, and
investigate any patient, provider, or transplant center barriers to implementation.

Aim 4 Determine the costs of delivering the TAKE IT strategy from a transplant center
perspective.

Additionally, the investigators will closely evaluate the implementation of all components of
the TAKE IT strategy from launch through 2 years follow-up (Aim 2). Their evaluation will
include a range of process outcomes to assess the intervention's reliability and
sustainability. These findings will determine whether any specific modifications to the TAKE
IT strategy are necessary (Aim 3). Finally, the team will estimate the incremental costs of
implementing and sustaining the TAKE IT strategy from the perspective of two transplant
centers (Aim 4).

Inclusion Criteria:

- 1) age 18 or older

- 2) within 3 months of KT (de novo) or 18-36 months post-KT (established)

- 3) English speaking

- 4) primarily responsible for administering own medication

- 5) own a cell phone and comfortable receiving text messages

- 6) access and proficiency using internet in home.

Exclusion Criteria:

- any severe, uncorrectable vision, hearing or cognitive impairments