| Data: |
2020 |
| Resum: |
La multimorbiditat i complexitat terapèutica poden comprometre els resultats en salut en poblacions cròniques d'elevada complexitat. Baixes xifres d'adherència terapèutica podrien estar relacionades amb aquesta complexitat, i resulten ser una causa directa de pèrdua de l'empelt i mort després d'un trasplantament cardíac. Les creences negatives del pacient versus la seva pauta terapèutica poden estar al seu torn afectant l'experiència del pacient i a l'adherència a les recomanacions. Molt poc es sap sobre la magnitud real en el nostre entorn d'aquest problema, quins són els instruments per a mesurar-lo, així com quines són les estratègies més eficients per a reduir el seu impacte. Tenint en compte aquesta problemàtica, es van implementar 4 fases abreujades com l'estudi mHeart (The mHeart Study). Els objectius de cadascuna de les fases van donar lloc a aquesta tesi doctoral dividida en 4 sub-estudis consecutius. La primera de les fases va ser dirigida a mesurar quantitativament la complexitat terapèutica mitjançant un índex àmpliament validat en patologia crònica i descrit en la literatura, així com la mesura de la càrrega de morbiditat que suporten les persones trasplantades cardíaques en estadi crònic (. |
| Resum: |
La multimorbilidad y complejidad terapéutica pueden comprometer los resultados en salud en poblaciones crónicas de elevada complejidad. Bajas cifras de adherencia terapéutica podrían estar relacionadas con dicha complejidad, y resultan ser una causa directa de pérdida del injerto y muerte tras un trasplante cardíaco. Las creencias negativas del paciente versus su pauta terapéutica pueden estar a su vez afectando a la experiencia del paciente y a la adherencia a las recomendaciones. Muy poco se sabe sobre la magnitud real en nuestro entorno de este problema, cuáles son los instrumentos para medirlo, así como cuáles son las estrategias más eficientes para reducir su impacto. En base a la problemática, se implementaron 4 fases abreviadas como el estudio mHeart (The mHeart Study). Los objetivos de cada una de las fases dieron lugar a esta tesis doctoral dividida en 4 sub-estudios consecutivos. La primera de las fases fue dirigida a medir cuantitativamente la complejidad terapéutica mediante un índice ampliamente validado en patología crónica y descrito en la literatura, así como la medida de la carga de morbilidad que soportan las personas trasplantadas cardíacas en estadio crónico (. |
| Resum: |
Multimorbidity and therapeutic complexity are undermining health outcomes in chronic populations such as the outpatient heart transplant (HTx) recipients. Medication nonadherence may be a consequence of this complexity and is a direct cause of graft loss and death after HTx. Nevertheless, even these are recognized problems, little is known about how best to quantify this complexity or the strategies that could reduce its burden. Based on this background, four sequential phases were implemented and abbreviated as The mHeart Study. This thesis is the result of the specific goals of these phases, presented as consecutive studies. All of them were conducted in the outpatient setting of the Heart Transplant Unit of a tertiary university hospital. The first phase aimed to quantitatively measure therapeutic complexity by using a validated quantitative index in chronic-stage HTx recipients. Therapeutic complexity observed was the highest compared with those previously published in chronic diseases and was mainly influenced by a higher count of drugs to treat comorbidities. Based on the results obtained in the first study, strategies were urgently needed to reduce post-HTx complexity. Therefore, the second phase aimed to develop the mHeart software and to implement an eHealth behavioral-based intervention model to provide healthcare to complex populations in the outpatient setting. The study the model implemented, outlines the facilitators and barriers, and the willingness to use the model reported by potential users. The tool was seek to improve medication safety and efficacy, to enhance patient-providers interactions and to provide comprehensive clinical care. Clinical pharmacists' skills on patient engagement, motivational interviewing and managerial experience were essential to lead the implementation. The patients confirmed that 98% of them were willing to use the mHeart system. The third study came to validate the main clinical aim of the mHeart tool, which is to improve medication nonadherence in HTx recipients. With this aim in mind, the mHeart strategy designed consisted of an intensive follow-up program based on multilevel individually-tailored digital interventions aiming to change behavior by a pharmacist using the mHeart technology in an interdisciplinary environment. The mHeart electronic patient-reported outcome measures (ePROMs) met the existing quality standards, and the exploratory clinical intervention established showed a promising improvement of 30% in medication adherence rates. These results supported the mHeart mobile application widespread use in larger research and usual clinical practice. Based on above-mentioned stages, this thesis work went further including a randomized clinical trial. An alarming 36% of the recipients were non-adherent to immunosuppressive treatment at baseline according to the SMAQ test, and 41% of patients were unaware of the consequences of forgetting to take their antirejection medicines. Therefore, the main objective of this long-term study was to improve recipients' adherence to immunosuppressive medication, their experience of therapeutic regimens, and to optimize in-clinic healthcare delivery. The intervention consisted of a long-term mHeart strategy versus a traditional in-clinic follow-up by a multidisciplinary team. The mHeart strategy positively impacted on the health outcomes preestablished. At the end of the study, medication adherence rates were statistically significantly improved in the intervention group (85%) versus the control group (46%). Furthermore, the strategy had a positive impact on patients' experience of therapeutic regimens and showed statistically significant reductions in the number of patients needing to travel to the clinic for follow-up appointments. The implications of the thesis will be a promising starting point for an emerging way of providing further assistance to the most complex populations based on eHealth. |
| Drets: |
Aquest document està subjecte a una llicència d'ús Creative Commons. Es permet la reproducció total o parcial, la distribució, i la comunicació pública de l'obra, sempre que no sigui amb finalitats comercials, i sempre que es reconegui l'autoria de l'obra original. No es permet la creació d'obres derivades.  |
| Llengua: |
Anglès |
| Col·lecció: |
Programa de Doctorat en Medicina |
| Document: |
Tesi doctoral ; Text ; Versió publicada |
| Matèria: |
Salut mòbil ;
Trasplantament cardíac ;
Tractament farmacològic ;
Salud móvil ;
Mhealth ;
Trasplante cardíaco ;
Heart transplant ;
Tratamiento farmacològico ;
Medication ;
Ciències de la Salut |
| ISBN: |
9788449095733 |
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