Psychosocial Assessment Of Candidates For Transplantation Research Articles

Turkish Validity and Reliability Study of the Scale of Psychosocial Assessment of Candidates for Transplantation (PACT)

The Psychosocial Assessment of Candidates for Transplantation (PACT) scale shows a statistically acceptable level of reliability and validity and can guide clinicians in managing transplant candidates. This study aims to adapt PACT scale to Turkish and evaluate its validity and reliability for Turkish transplant candidates. This was a psychometric study of a sample of 162 patients in the organ transplant services of 2 hospitals in Turkey. The number of patients enrolled in the study was 20 times the number of items on the scale. The research data were collected using PACT. Descriptive statistics, Cronbach's alpha reliability coefficient, Pearson correlation, and factor analysis were used to evaluate the data. The data were analyzed using varimax rotation in principal component analysis. The factor loadings of the items ranged from 0.56 to 0.79. The internal reliability coefficient of the scale is 0.87. It was also found that the scale accounted for the 52.82% of the total variance. According to the results of this study, evidence of the validity and reliability of the PACT was obtained.

The Effect of Pre-Transplant Psychosocial Problems on Kidney Transplantation Outcomes

Introduction: The present study aimed to evaluate the association between the pre-transplant psychosocial profile and kidney transplant candidates' clinical outcomes.Methods: The present study population included all patients assessed for kidney transplant candidacy in Sina Hospital, Tehran University of Medical Sciences. The 42 patients who were candidates for kidney transplantation were enrolled in the present study. The mental health was measured by psychosocial assessment of candidates for transplantation (PACT) questionnaire. A global score of equal or lower than 2 was categorized as a low PACT score and equal and higher than 3 was defined as a high score. PACT questionnaire was completed before the kidney transplantation for each patient. The outcomes of our study were post-transplant dialysis, time of dialysis, hospital stay after transplant, rejection after transplant, time of rejection after transplant, delayed graft function, re-hospitalization after transplant, and time of re-hospitalization that were followed after transplantation. Results: A total of 42 patients underwent kidney transplantation; 15 ( 35.7%) patients had a poor PACT score while 27 (64.3%) patients had a high PACT score. There were no significant differences in age, sex, marital status, literacy, insurance, supplementary insurance, smoking, being head of household between the two groups. There were no significant differences between the two groups in clinical characteristics after kidney transplantation (P-value > 0.05). Conclusions: In our study, there was no significant association between psychosocial status and clinical outcomes and it has been suggested that more studies are needed in this field

Psychosocial Assessment of Candidates for Transplantation (PACT) Score Identifies High Risk Patients in Pediatric Renal Transplantation.

Background: Currently, there is no standardized approach for determining psychosocial readiness in pediatric transplantation. We examined the utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) to identify pediatric kidney transplant recipients at risk for adverse clinical outcomes.Methods: Kidney transplant patients <21-years-old transplanted at Duke University Medical Center between 2005 and 2015 underwent psychosocial assessment by a social worker with either PACT or unstructured interview, which were used to determine transplant candidacy. PACT assessed candidates on a scale of 0 (poor candidate) to 4 (excellent candidate) in areas of social support, psychological health, lifestyle factors, and understanding. Demographics and clinical outcomes were analyzed by presence or absence of PACT and further characterized by high (≥3) and low (≤2) scores.Results: Of 54 pediatric patients, 25 (46.3%) patients underwent pre-transplant evaluation utilizing PACT, while 29 (53.7%) were not evaluated with PACT. Patients assessed with PACT had a significantly lower percentage of acute rejection (16.0 vs. 55.2%, p = 0.007). After adjusting for HLA mismatch, a pre-transplant PACT score was persistently associated with lower odds of acute rejection (Odds Ratio 0.119, 95% Confidence Interval 0.027–0.52, p = 0.005). In PACT subsection analysis, the lack of family availability (OR 0.08, 95% CI 0.01–0.97, p = 0.047) and risk for psychopathology (OR 0.34, 95% CI 0.13–0.87, p = 0.025) were associated with a low PACT score and post-transplant non-adherence.Conclusions: Our study highlights the importance of standardized psychosocial assessments and the potential use of PACT in risk stratifying pre-transplant candidates.

Psychosocial Risk Impacts Mortality in Women After Liver Transplantation

Liver transplant candidates undergo psychosocial assessment as a component of their pretransplant evaluation. Global psychosocial assessment scales, including the Psychosocial Assessment of Candidates for Transplantation (PACT), capture and quantify these psychiatric and social variables. Our primary aim was to assess for an association between global PACT score and survival in liver transplant recipients. This retrospective cohort study examined records of all liver recipients at one U.S. Transplant Center from 2000 to 2012 with outcomes monitoring until 07/01/2016. We investigated for associations between the following variables and mortality: PACT score, age, gender, marital status, race, alcoholic liver disease (ALD), and body mass index (BMI). Statistical methods included Student's t-test, Wilcoxon rank sum test, chi-square, Fisher's exact test, Kaplan-Meier curve, and Cox proportional hazard models. Of 1040 liver recipients, 538 had a documented PACT score. Among these, PACT score was not associated with mortality. In women, a lower PACT score was associated with mortality (p = 0.003) even after adjustments for age, marital status, and BMI. Women with ALD had a 2-fold increased hazard of death (p = 0.012). Increasing age was associated with increased risk of death for the cohort as a whole (p = 0.019) and for men (p = 0.014). In men, being married and BMI were marginally protective (p = 0.10 and p = 0.13, respectively). Transplant psychosocial screening scales, specifically the PACT, identify psychosocial burden and may predict post-transplant outcomes in certain populations. In female liver recipients, lower PACT scores and ALD were associated with a greater risk of post-transplant mortality.

Psychosocial Risk Predicts New Episode Depression After Heart Transplant

Psychosocial assessment is an essential component of the pretransplant evaluation. Many individuals have significant psychosocial problems, and they are either denied for transplantation or deferred from listing and transplant until the psychosocial issues are addressed. The primary aim of this study was to evaluate the outcomes of patients who initially had significant psychosocial problems, but who addressed them and received a heart transplant. This retrospective study included heart transplant recipients from 1/1/2000 to 12/31/2012. Those with initial Psychosocial Assessment of Candidates for Transplantation (PACT) scale score <2 were compared with those whose initial score was ≥2 for the variables new onset depression and anxiety, length of stay, rejection, and survival using logistic and linear regression and Cox proportional hazards modeling. Of 164 heart recipients with pretransplant PACT scores, 46 (28%) were female, 154 (94%) were white, and the mean age was 52.7years. Only 11 (7%) received an initial PACT score <2; these candidates underwent heart transplantation after their scores increased to ≥2. Initial PACT <2 increased the odds of new depression by 11-fold (p = 0.002), but was not associated with differences in survival, posttransplant length of stay, the occurrence of treated episodes of rejection or new anxiety (p ≥ 0.20 for all). Among heart recipients, initially high pretransplant psychosocial risk, as assessed by PACT, was associated with posttransplant new episode depression. However, after addressing the primary psychosocial issues before transplant, posttransplant length of stay, organ rejection, and survival were the same as those without prior psychosocial concerns.

Utility of the Psychosocial Assessment of Candidates for Transplantation in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation.

Psychosocial assessment of patients comprises an important element in the selection process of appropriate candidates for left ventricular assist device (LVAD) implantation. We sought to determine the association of the well-validated psychosocial assessment of candidates for transplantation (PACT) scale to clinical outcomes post-LVAD implantation. The PACT scale was used retrospectively to reconstruct psychosocial profiles of all patients who underwent a continuous-flow LVAD implantation for all indications at our institution between March 2008 and August 2012 (N = 230). Psychosocial elements including social support, psychological health, lifestyle factors, comprehension of the operation, and follow-up were evaluated. The primary outcome was overall survival, and the secondary outcomes were hospital readmission, pump thrombosis, hemolysis, gastrointestinal (GI) bleeding, and LVAD driveline infections. The mean age of patients was 55.3 years, with 83% being male; 58% (N = 135) were bridge to transplant and 42% (N = 95) were destination therapy. Up to 1-year post-LVAD implant, there were no statistical differences among the 5 PACT candidate groups in terms of survival ( P = .79), hospital readmissions ( P = .55), suspected or confirmed pump thrombosis ( P = .31), hemolysis ( P = .43), GI bleeding ( P = .71), or driveline infections ( P = .06). In this single-center retrospective review, post hoc reconstruction of psychosocial profiles using the PACT scale and independent assessment of postimplant outcomes, including survival and adverse events, did not show any association. However, given the small number of patients in the low score PACT groups as well as limited duration of follow-up, further studies are required to elucidate the association.

Development of the Japanese Version of the Psychosocial Assessment of Candidates for Transplantation in Allogeneic Hematopoietic Stem Cell Transplantation

The Psychosocial Assessment of Candidates for Transplantation (PACT) is a validated instrument for evaluating psychosocial risk factors in transplant candidates. This study examined reliability and validity of the Japanese version of the PACT (J-PACT). PACT is a clinician-rated scale consisting of an initial rating, 8 subscales, and a final rating. J-PACT was developed through a translation and back-translation procedure. Seventy adult patients who underwent allogeneic hematopoietic stem cell transplant between April 2009 and December 2013 received retrospective J-PACT ratings based on medical records. Interrater reliability and concurrent validity with Hospital Anxiety and Depression Scale (HADS) and Profile of Mood Status (POMS) scores were assessed. Interrater reliability for each J-PACT item was generally high, ranging from 0.53 (drug and alcohol use)-0.93 (support stability). The concurrent validity analyses revealed the following significant relationships (p < 0.05). Higher support stability was associated with lower HADS depression (p = 0.02), POMS anger (p = 0.001), POMS fatigue (p = 0.03), and POMS confusion (p = 0.01) scores. Higher support availability was associated with lower POMS anger scores (p = 0.01). More suitable personality was associated with lower HADS anxiety (p = 0.04) and HADS depression (p = 0.048) scores. Better scores on lifestyle factors and alcohol use were both associated with lower POMS confusion scores (p = 0.01, 0.04, respectively). Better final rating was associated with lower HADS anxiety (p = 0.03) and HADS depression (p = 0.02) scores. J-PACT was reliable and valid, although further study is needed to confirm these findings.

Higher Hematopoietic Cell Transplant Comorbidity Index (HCT-CI) Is Associated with Poor Psychosocial Health Pre-Autologous Stem Cell Transplantation (ASCT) in Lymphoma Patients

The assessment of pre-transplant comorbidities is crucial for risk-stratification and is a tool to guide clinical decisions in hematological malignancy patients (pts) undergoing evaluation for stem cell transplantation (SCT). The HCT-CI scale is commonly used to identify high risk patients pre-transplant as it is highly predictive of non-relapse mortality (NRM), severity of graft versus host disease and survival after allogeneic SCT (Sorror et al, Blood 2005; Sorror et al, Blood 2014). However, its role in ASCT remains undefined. In a Center for International Blood and Marrow Transplant Research analysis, HCT-CI score of ≥3 was prognostic for higher NRM and overall mortality in ASCT patients (Sorror et al, Biol. Blood Marrow Transplant 2015), but other single institution studies have failed to confirm this observation in lymphoma patients (Jaglowski et al, Bone Marrow Transplant 2014; Dahi et al, Biol. Blood Marrow Transplant 2014; Hosing et al, Ann. Oncol. 2008). No study has correlated HCT-CI with psychosocial functioning in the setting of ASCT.We conducted a retrospective study of 350 patients with Hodgkin (N=70) and non-Hodgkin Lymphoma (N=280) who underwent ASCT at our institution from January 2009 to June 2015. Based on their HCT-CI score, patients were categorized into low risk (score 0, N=90), intermediate risk (score 1-2, N=123) and high risk (score ≥3, N=137). Psychosocial Assessment of Candidates for Transplantation (PACT) scale (0-4: 0 being poor candidate for procedure and 4 being excellent candidate) (Foster et al. BMT 2009) was used for pre-transplant psychosocial risk assessment and was available for 235 pts. We analyzed the impact of HCT-CI on transplant outcomes and its correlation with PACT scores.Our cohort was predominantly male (63%), and Caucasian (93%) with a median age of 55 years (range 20-78). The majority of the pts (96%) had good performance status with an ECOG of 0-1. The primary diagnosis was NHL in 80%, with mostly advanced stage disease (80%), and no B symptoms (93%). Median time from diagnosis to ASCT was 16 months with 75% of the pts having received ≤2 prior therapies. The median annual income based on zip code was $49406 (range $18753-127312). Disease status prior to transplant was CR/PR in 93% of the subjects. Patient and disease characteristics were comparable among the 3 HCT-CI risk groups. Higher HCT-CI risk category was associated with a lower median household income (p=0.012), higher LDH (p=0.004), more days of apheresis (p=0.026) and lower CD34+ dose x106/kg (0.046). In relation to PACT scores, higher HCT-CI was associated with poor mental health (p<0.001), decreased coping skills (p<0.001), unhealthy lifestyle habits/sedentary life (p<0.001), decreased compliance with medications/medical advice (p=0.014) and inadequate medical/transplant knowledge (p=0.017) and lower final PACT score (p<0.001). Median follow up was 35 months with 100 observed deaths, of which 72 were attributed to relapse. The 5 year estimated relapse rate, NRM, relapse free survival (RFS) and overall survival (OS) in our cohort were 42%, 11%, 49% and 62% respectively. On univariate analysis, there was no significant difference between high vs. low/intermediate HCT-CI scores on 30 day readmission rates (OR 1.24, p=0.61), 100 day mortality (OR 1.12, p=0.86), incidence of secondary malignancy (HR 0.41, p=0.17), relapse rate (HR 0.92, p=0.64), relapse mortality (HR 1.35, p=0.20), NRM (HR 0.86, p=0.71), OS (HR 1.2, p=0.37) or RFS (HR 0.98, p=0.92). Though not statistically significant, the intermediate risk group was noted to have higher 100 day mortality and NRM compared to the low and high risk groups.To our knowledge, this is first study to correlate pre-transplant HCT-CI with PACT scores in lymphoma pts who underwent ASCT. Higher HCT-CI was associated with lower socioeconomic status, poor mental health and coping skills, unhealthy lifestyle habits, decreased medical/transplant knowledge and compliance. HCT-CI did not predict survival in our cohort. Further studies are needed to investigate the association between psychosocial risk factors and HCT-CI and define their combined utility in pre-transplant risk assessment in ASCT patients. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Psychosocial Assessment of Candidates for Transplantation (PACT) Score as Predictor of New Episode Depression among Heart Transplant Recipients

Psychosocial Assessment of Candidates for Transplantation (PACT) Score as Predictor of New Episode Depression among Heart Transplant Recipients

Association between initial psychosocial assessment of candidates for transplantation (PACT) score and mortality among lung transplant recipients at Mayo Clinic, Rochester

Association between initial psychosocial assessment of candidates for transplantation (PACT) score and mortality among lung transplant recipients at Mayo Clinic, Rochester

Psychosocial assessment of candidates and risk classification of patients considered for durable mechanical circulatory support

The psychosocial assessment of candidates for transplantation (PACT), developed to assess candidates for heart transplant, has not been routinely used to assess left ventricular assist device (LVAD) candidacy. We examined the efficacy of the PACT to assess psychosocial outcomes in LVAD patients. We reviewed patients who received LVAD implants between June 2006 and April 2011 and retrospectively applied the PACT. We determined the accuracy of identifying social success with the PACT and revised domains to reflect criteria influencing social success for LVAD patients. Forty-eight patients (72% men, 44% non-white, 50.4 years old) were divided into high-scoring and low-scoring groups. Nine patients with low PACT scores were falsely categorized as high-risk, whereas 4 with high scores had poor social outcomes. The score had a high positive-predictive value (0.86) but low negative-predictive value (0.31). The PACT was revised (modified [m]PACT) to measure indicators, such as social support and understanding of care requirements, identified to more closely affect LVAD outcome. The mPACT exhibited improved accuracy. A reclassification table was developed, and the net reclassification index was 0.32. The percentage of patients incorrectly classified for social risk decreased from 27% with the PACT to 8% with the mPACT. Patients with higher mPACT scores had decreased 30-day readmission rates (26% vs 67%, p = 0.045) after device implantation. By emphasizing social support, psychologic health, lifestyle factors, and device understanding, the mPACT showed improved performance in risk-stratifying candidates for LVAD therapy. Prospective validation is warranted.

(589) - Psychosocial Assessment of Candidates for Transplantation Score and Readmissions in HeartMate II Bridge to Transplant Left Ventricular Assist Device Patients

The psychosocial assessment of candidates for transplantation (PACT) score is well validated in transplant populations but is not well studied in bridge to transplant (BTT) LVAD (left ventricular assist device) recipients. We sought to characterize PACT score impact in BTT patients receiving a HeartMate II (HM2) device. All BTT patients that underwent HM2 LVAD implant from January 2008 to July 2013 were retrospectively analyzed. PACT scores were completed in 51 of the 71 total patients prior to LVAD implant. Transplantation was considered an endpoint. Patients that died during initial LVAD hospitalization were excluded. We reviewed readmissions after initial LVAD hospitalization in the 48 remaining patients with PACT scores. We identified 48 patients with PACT scores ranging from 1 to 4. Due to small sample size and potential skewing of outliers, we used mode to determine readmissions for each PACT score. A mode of 2, 1, 0, and 0 readmissions was associated with a PACT of 1, 2-2.5, 3, and 4, respectively (Figure 1). 0% of patients with a PACT of 1, 43% with a PACT of 2-2.5, 63% with a PACT of 3, and 67% with a PACT of 4 were transplanted (Figure 2). Statistical significance was not achieved due to small sample size. Higher PACT scores correlated with fewer readmissions and greater percentage of patients undergoing heart transplantation in HM2 BTT LVAD patients. No such score exists for destination therapy (DT) LVAD patients. Implementing PACT scores for DT LVAD recipients may hold potential to aid in predicting readmissions.FigView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) Scale in Patients Undergoing Mechanical Circulatory Support

Psychosocial assessment of patients comprises an important element in the selection process of appropriate candidates for left ventricular assist device (LVAD) implantation. We sought to determine the association of the well-validated psychosocial assessment of candidates for transplantation (PACT) scale to clinical outcomes post LVAD implantation.

Modification of the Psychosocial Assessment of Candidates for Transplantation (PACT) Improves Risk Classification and Prediction of Hospital Readmission of MCS Patients

Purpose We previously demonstrated that the PACT falsely characterized some patients (pts) considered for MCS therapy as high risk. We developed and evaluated a new MCS-specific PACT; thus, the purpose of this study was to examine the sensitivity and specificity of this revised instrument to classify MCS pts. Methods and Materials PACT domains were re-written to reflect psychosocial criteria influencing social success defined as a reliable support system, discharge on schedule, and no social re-admissions. Areas of concern for HT candidates were eliminated and social support was emphasized. A social worker, blinded to outcomes, re-scored previously studied pts with the revised instrument. mPACT and PACT scores were then compared. Team members were surveyed: Was this pt a social success? Answers were assigned a value [no=0, yes=1] to determine a social success score. Success was considered a mean score >.5. Results 48 pts (72% men, 44% AA, 50.4 yrs) supported on MCS for 274 days were evaluated. The sensitivity of a score of 17 to identify a social success was .97 and the specificity was .56. The PPV was .97 and NPV was .56, compared to .86 and .44 respectively, for the PACT. A reclassification table was developed to assess the difference in risk stratification of the mPACT compared to the PACT. Net reclassification showed 19% improvement in risk stratification by the mPACT. Five of the 9 patients falsely categorized as high risk by the original PACT score were appropriately re-categorized as low risk with the mPACT. Patients with an mPACT score Conclusions By eliminating risk factors that do not have the same bearing on MCS outcome as HT and emphasizing areas of social support, we appropriately re-classified patients as acceptable risk who had been incorrectly considered high risk by the PACT. The mPACT score showed improved performance and warrants prospective validation.

The Positive Effect of Inpatient Care-Partners During Allogeneic Bone Marrow Transplantation; A Prospective Trial

AbstractAbstract 931We have previously reported a retrospective study describing the positive impact on survival of allogeneic bone marrow transplant (BMT) recipients having a consistent care-partner during their inpatient hospitalization. To validate these observations, in 2003 we launched a prospective trial comparing the clinical and psychosocial outcomes of ablative allogeneic BMT patients with inpatient care-partners to those who did not have a care-partner.Every ablative allogeneic BMT patient transplanted from 10/03 – 11/08 was asked to enroll on this study and 164 of 213 enrolled. Reasons for not participating were medical illness severity precluding completion of psychosocial form, language barriers, and care-partners unwilling to participate. As part of the study, BMT social workers completed a Psychosocial Assessment of Candidates for Transplantation (PACT) scale, and patients completed three psychometric instruments: Brief COPE scale, Functional Assessment of Cancer Therapy – Bone Marrow Transplantation (FACT-BMT) scale, and Profile of Mood States – Short Form (POMS) at five time points (pre-admission to 12 months post transplant). For the purposes of this study, a consistent care-partner was defined as one person being on the inpatient BMT unit with the patient five or more days per week. The total study population was 164 patients, 88 with care-partners and 76 without. The most common diagnosis was AML, followed by ALL, MDS, and CML. There was no difference between groups with and without care-partners in primary diagnosis, time from diagnosis to transplant, related versus unrelated transplants, disease status, donor source, co-morbidity status or age (median age was 44 years old). At baseline, patients with a care-partner had better physical wellbeing on FACT-BMT (p=0.014) and better (lower) scores for substance use on Brief COPE (p=0.007), but worse scores for planning (p=0.049) then patients with no care-partner. There were no significant differences of mood state scores between the two groups at baseline. The median follow-up is 41.2 months (range 16.4 – 73.7). The amount of time the care-partner actually stayed with the patient was recorded on a weekly log. Sixty percent of care-partners were spouse and thirty percent were parents. Sixty-six percent were employed and fourteen percent were retired. Eighty-seven percent lived with the patient prior to admission. The care-partners were with the patients a median of 7.5 hours per day. As shown below, patients with a consistent care-partner had a statistically significant improvement in survival. [Display omitted] Twenty-nine percent of patients without care-partners are still alive versus forty-seven percent of those with care-partners. The survival curves diverge approximately six months post transplant. Forty-six percent of patients in the non care-partner group died of infections/pneumonia, or other organ failure versus twenty-five percent in the care-partner group. Univariable and multivariable analysis confirmed that the presence of a consistent care-partner favorably influenced survival.In conclusion, we have verified our retrospective observation that the presence of a consistent care-partner improves survival. The mechanisms are unclear. The fact that the survival curves begin to diverge six months post transplant suggest that the benefit of a consistent care-partner during the hospitalization may translate into extended benefits post transplant. Alternatively, the care-partner relationship may be more important post-transplant and influence compliance or other variables. Our goal for future research is to attempt to define the benefit of the care-partner relationship and determine interventions for those without care-partners. Disclosures:No relevant conflicts of interest to declare.

Utility of the psychosocial assessment of candidates for transplantation (PACT) scale in allogeneic BMT

The psychosocial assessment of candidates for transplantation (PACT) scale was completed before the transplant on 120 patients who underwent allogeneic transplant from November 2003 to June 2007. The PACT has eight subscales, each rated on a 5-point scale, and an initial and final rating independently based on the rater's overall impressions of the candidate's acceptability for transplant. This exploratory study assessed the clinical utility of the PACT scale for psychosocial screening in allogeneic BMT. Associations of the PACT subscales and the final rating with sixteen post transplant medical outcomes were examined using the Jonchkheere-Terpstra test, the Cochran-Armitage test or the Cox proportional hazards analysis. Significant relationships (P<or=0.05) between PACT subscales and medical outcomes are as follows: better compliance with medications and medical advice associates with lower in-hospital mortality, shorter length of stay and readmission duration, and faster neutrophil and platelet engraftment; better scores on drug/alcohol use associates with faster platelet engraftment; better scores on family/support system availability and on relevant knowledge and receptiveness to education associates with decreased risk of mortality. The final rating score and medical outcomes are not significantly related; however, study findings underscore the prognostic value of the PACT subscales and the potential utility for screening of BMT candidates.

Utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) Scale in Allogeneic BMT

The psychosocial assessment of candidates for transplantation (PACT) scale was completed before the transplant on 120 patients who underwent allogeneic transplant from November 2003 to June 2007. The PACT has eight subscales, each rated on a 5-point scale, and an initial and final rating independently based on the rater’s overall impressions of the candidate’s acceptability for transplant. This exploratory study assessed the clinical utility of the PACT scale for psychosocial screening in allogeneic BMT. Associations of the PACT subscales and the final rating with sixteen post transplant medical outcomes were examined using the Jonchkheere–Terpstra test, the Cochran–Armitage test or the Cox proportional hazards analysis. Significant relationships (Pp0.05) between PACT subscales and medical outcomes are as follows: better compliance with medications and medical advice associates with lower in-hospital mortality, shorter length of stay and readmission duration, and faster neutrophil and platelet engraftment; better scores on drug/alcohol use associates with faster platelet engraftment; better scores on family/support system availability and on relevant knowledge and receptiveness to education associates with decreased risk of mortality. The final rating score and medical outcomes are not significantly related; however, study findings underscore the prognostic value of the PACT subscales and the potential utility for screening of BMT candidates.

Psychosocial predictors of psychiatric disorders after living donor liver transplantation

Objective. Adult recipients of living donor liver transplantation (LDLT) often have psychiatric disorders before and after surgery. The aim of this study was to investigate pretransplant psychosocial factors that can be used to predict psychiatric disorders after LDLT. Methods. The subjects were 67 recipients of adult-to-adult LDLT at Kyoto University Hospital, Japan, from November 2001 through July 2003. All subjects were interviewed and examined by means of the Beck Depression Inventory, State-Trait Anxiety Inventory, World Health Organization Quality-of-Life Assessment-26, and Psychosocial Assessment of Candidates for Transplantation (PACT) just before LDLT. The subjects were followed up for 90 days for the presence of psychiatric disorders. Results. Mood disorders in the past, inability to maintain a healthy lifestyle, family support instability, and suicidal ideation just before LDLT might be predictors of major depressive disorder after LDLT. Delirium just before LDLT might be a predictor of delirium after LDLT, while no psychosocial factors associated with posttransplant delirium could be found. Conclusion. Information about life history rather than any psychological examination is important for predicting the occurrence of posttransplant depression. PACT is useful for obtaining information about the life history of LDLT recipients.

Predictive Value of the Psychosocial Assessment of Candidates for Transplantation (PACT) Scale in Allogeneic BMT.

Purpose: Psychosocial risk factors have been reported to be associated with or predictive of treatment-related vulnerability and survival in allogeneic BMT. Recent survey research revealed that BMT clinicians consider psychosocial risk factors when making a decision whether or not to proceed with allogeneic BMT. The Psychosocial Assessment of Candidates for Transplantation (PACT) scale, a tool designed to study the psychosocial screening process and uniformity of decision-making in solid organ transplantation, has been utilized in BMT, but there is no research as to the relationship of the scores of psychosocial risk to medical outcomes, either in BMT or solid organ transplantation. This research analyzes the predictive value of PACT scale scores in relation to medical outcomes in allogeneic BMT.Methods: From 11/2003 to 6/2007, 120 allogeneic BMT patients were assessed pre-transplant by oncology social workers who subsequently completed the PACT scale. The PACT scale has ratings for social support, psychological health, lifestyle factors, and understanding of transplant and follow-up. Data analyses examined relationships between the overall PACT score of a patient (ranging from low to high risk) and post-transplant medical outcomes and baseline quality of life, mood states, and coping with illness; instruments utilized to measure the latter three psychosocial variables, in order, are the Functional Assessment of Cancer Therapy scale (FACT) specific to BMT, Profile of Mood States (brief form), and Brief COPE.Results: There is no significant relationship between risk scores on the PACT scale and shorter-term medical outcomes (i.e., length of stay, in-hospital death, death within 100 days, days until engraftment, and readmissions) nor longer-term medical outcomes (i.e., GVHD, relapse, overall survival, and relapse free survival). However, there is a significant relationship between the patient's PACT score and pre-morbid psychosocial functioning. Lower risk PACT scores are associated with better quality of life; lower depression, anger, and confusion, higher vigor; and positive coping behaviors of self-distraction, positive reframing, and use of religion. Higher risk PACT scores are associated with negative coping behaviors of denial, substance use, and behavioral disengagement.Conclusions: Although the PACT scale as a measure of overall psychosocial risk has been promoted as a helpful tool for the pre-transplant psychosocial evaluation process, its' predictive value with respect to medical outcomes in BMT is arguable. However, that PACT scores associated with pre-morbid psychosocial functioning underscores the utility of the PACT scale for screening a cluster of psychosocial issues that may combine as risk factors for treatment related vulnerability. Determining patient eligibility for BMT based on overall psychosocial risk is not advisable; needed is research to further study which specific psychosocial risk factors, if any, are associated with, if not prognostic of, medical outcomes.

PROPOSED ROLE OF A BIOETHICIST IN P.A.C.T. (PSYCHOSOCIAL ASSESSMENT OF CANDIDATES FOR TRANSPLANTATION) SCORING

Purpose: Accepting that patient decision-making capacity and understanding of the transplant process are critical to obtaining informed consent, and that patient pre- and post-transplant compliance impact transplant morbidity and mortality, assessment of decision-making capacity, transplant understanding, and compliance is an important part of the transplant candidate selection process. We conceptually explored a possible role for a Bioethicist in assessing these transplant candidate variables in conjunction with the Social Worker's use of the PACT (Psychosocial Assessment of Candidates for Transplantation) rating scale. Methods: A literature review was conducted (Medline 1966-November 2002) regarding use of the PACT scale as a heart transplant candidate screening tool. Results: Two rating components of the PACT scale are “Compliance with Medications and Medical Advice” and “Understanding of Transplant and Follow-Up”. Due to the nature of allografts as a scarce resource, it is imperative that allocation favor patients who will likely benefit most (improved quality of life and duration of improved quality of life). It is concluded that due to the Bioethicist's training and expertise in matters of decision-making capacity, informed consent, and compliance, a Bioethicist might be an effective participant in the heart transplant candidate selection process using the PACT scale. Future study will apply this conceptual notion in the patient setting, exploring the feasibility of a Social Worker-Bioethicist partnership, as well as the effect of the partnership on cardiac transplant outcomes.