Many transplant recipients may experience physical and emotional symptoms, such as anxiety, fatigue, sleep problems, pain, etc. Often, these symptoms are not reported or managed well, and can affect a patient's quality-of-life. Transplant recipients are grateful for the "gift of life" but physical and emotional symptoms reduce their quality-of-life. Transplant recipients and caregivers have felt unprepared for the ongoing symptoms and reduced quality-of-life post-transplant.
One way of monitoring and managing these symptoms is using the Emotion And Symptom-focused Engagement (EASE) intervention. EASE was originally developed for patients with acute leukemia and has begun to be adapted to help monitor and manage physical and emotional symptoms for organ transplant recipients.
EASE is comprised of two components:
1. Psychological - 8 supportive counselling sessions delivered by mental health clinicians to address concerns about mental health, losses from organ failure, coping with a transplant, experiences with living on the brink of death for a prolonged period of time, etc. 2. Physical - Regular assessments of physical symptoms using questionnaires and referral to healthcare professionals for symptom management as necessary.
EASE uses questionnaires, also called patient reported outcome measures (PROMs), for symptom assessment and monitoring. PROMs measure symptom severity, similarly to how bloodwork measures organ functioning. PROMs, as part of EASE, will ask recipients questions and help identify relevant physical, emotional, and social symptoms to enhance their care.
With the help of specialists, patients, and support from the Kidney Foundation of Canada, our team has begun to adapt the EASE intervention for transplant recipients. In order to finalize the adaptation of the EASE intervention for use in a routine transplant clinic, we are launching a pre-pilot study to gain real-life experience from managing symptoms of SOT recipients with the use of EASE-SOT.
Participants consented pre-transplant: Potential transplant recipients who are listed on the waitlist and are identified by pre-transplant staff, recipients who have a living donor arranged (pertaining to kidney and liver recipients), participants currently completely pre-transplant prehabilitation (pertaining to lung and heart recipients), or those who are on the top of their respective organ transplant waitlists.
Participants consented post-transplant: Incident kidney, kidney-pancreas, liver, lung, or heart transplant recipients identified during index transplant hospital admission at the inpatient transplant unit of the Ajmera Transplant Centre at Toronto General Hospital
Patients in ICU.
Patients who are clinically unstable, have delirium or other severe mental health concern requiring psychiatric treatment - assessed by clinical team.
Non-English speaking patients.
Severe cognitive impairment as assessed by the recruitment and/or research team. This will be determined through communication with the organ transplant teams and by checking the patient's medical charts. If no cognitive impairment is indicated by the patients organ transplant team or is documented in their medical chart, the patient will be assessed to have no cognitive impairment.
Parallel
EASE-SOT
Other interventionEASE integrates supportive counseling and trauma-focused cognitive behavioral therapy (CBT) (EASE-psy) with systematic physical symptom screening and triggered referral to supportive care to manage moderate to severe physical symptoms (EASE-phys) using electronic patient reported outcome measures (ePROMs). The intervention duration is 8 weeks. Based on individual preference, EASE-psy may be administered in person or virtually via Microsoft Teams. Based on individual preference, participants may receive ePROMs either on tablets or to their personal electronic devices via email, while at the hospital ward and in clinics, ensuring easy access and administration of these tools.
Recruitment Target
Feasibility of the EASE-SOT intervention will be confirmed if our recruitment target of 120 participants (40 kidney and kidney-pancreas transplant recipients and 80 liver, lung, and heart transplant recipients) in a 30 month recruitment period is met.
Consent Rate
The consent rate describes the proportion of eligible patients who decline consent. Feasibility of the EASE-SOT intervention will be confirmed if the decline rate is ≤50%.
Retention Rate
The proportion of enrolled participants who continue to participate in the study at 8 weeks post-enrollment. Feasibility will be confirmed by a retention rate of 70%.
Adherence Rate
The proportion of enrolled participants who complete the EASE-Psy sessions, the symptom screening (EASE-phys) and outcome measures at the time offered, and have meetings the supportive care team if indicated by screens. Feasibility will be confirmed if ≥50% of participants complete EASE-psy sessions and symptom screening (EASE-phys) and outcome measures ≥50% of the time offered and have ≥1 meeting with the supportive care team if indicated by screens.
Incidence Rate of Healthcare Use
11-item recent healthcare use questions regarding healthcare use events such as recent hospitalizations, emergency visits, healthcare use. Incidence rates (event/100 patient years) of hospitalization, emergency admission, and hospitalization. Incidence rates will be compared between the two groups.
Post-transplant Quality of Life using the EQ-5D-5L
Measured by the the EuroQol-5 Dimension-5 Level (EQ5D5L) and Patient Reported Outcomes Measurement Information System (PROMIS) physical and mental health summary scores. The EQ5D5L measures quality of life (QOL) and utilities of health states by assessing mobility, self-care, usual activities, pain/discomfort, and anxiety/depression using a single item for each domain, measured on five response levels. We will use the Canadian value set. The PROMIS physical and mental health summary scores are calculated using responses to the domain specific item banks included in the PROMIS 29+2 v2.1 Profile measure.
Post-transplant Quality of Life using PROMIS physical and mental health summary scores
The Patient Reported Outcome Measurement Information System (PROMIS) 29+2 v1.2 profile assesses pain intensity using a single 0-10 numeric rating item, cognitive function using 2 items, and seven additional domains of health (physical function, fatigue, pain interference, depression, anxiety, ability to participate in social roles and activities, and sleep disturbance). The seven additional domains of health will be assessed using computer adaptive testing (CAT). The PROMIS 29 scales are scored on a T-score metric with a mean score of 50 and standard deviation of 10. For symptom domains, a higher score indicates a higher severity of that symptom. For function domains, a higher score indicates less impairment. The PROMIS physical and mental health summary scores are calculated using responses to the domain specific item banks included in the PROMIS 29+2 v2.1 Profile measure.
Presence of post-traumatic stress symptoms post-transplant using the SASRQ
Measured by the Stanford Acute Stress Reaction Questionnaire (SASRQ). The SASRQ is a 30-item questionnaire used to measure traumatic stress symptoms, including anxiety and dissociation symptoms, using a valid and reliable scale. The instructions were modified to refer to organ failure and the transplant surgery as the "traumatic event".
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