Construction of an index system for evaluating the effectiveness of transitional care in kidney transplant recipients

Background Previous studies showed that transitional care reduces the complication rate and readmission rate and improves the quality of life in kidney transplant receipts, nevertheless, in fact there are no standard evaluation indexes and debatable scientific of existing indexes in kidney transplant recipients. Therefore, the aim of this study was to construct an evaluation index system to assess the effects of transitional care in kidney transplant recipients. Methods Based on Omaha system, an initial evaluation index system about the effects of transitional care in kidney transplant recipients was drafted by the literature review and semi-structured interview. Two rounds of correspondence were conducted in 19 experts and the analytic hierarchy process (AHP) was used to calculate the weights of all indexes. Results Five first-level indexes, sixteen second-level indexes, and forty-eight third-level indexes were selected in the initial evaluation index system. The authority coefficient of two-round expert consultations was 0.90 and coordination coefficients of indexes ranged from 0.24 to 0.34. Conclusion The established evaluation index system for the effectiveness of transitional care for kidney transplant recipients was scientific and reliable. Furthermore, it would be a potential method to evaluate effects of transitional care in kidney transplant recipients after further examination. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01496-9.

care. However, at present, there are no standard evaluation indexes and debatable scientific of existing indexes in chronic disease transitional care in China [10]. Some researchers have explored the construction of a standardized evaluation index system in people with stroke [11], coronary heart disease [12] and other diseases, and some researchers have also explored the construction of a transitional care evaluation index system for the entire chronic disease population [13]. However, in the field of kidney transplant recipients, a standardized and systematic index system for evaluating the effectiveness of transitional care has not been developed, and the index system for evaluating the chronic disease population is not disease-specific and lacks evidence-based studies.
Therefore, present study used the Omaha system as the theoretical framework and Delphi method combined with analytic hierarchy process (AHP) to construct an index system for evaluating the effectiveness of transitional care in kidney transplant recipients.

Objective
The objective of this study is to provide a reference for scientific and effective evaluation of transitional care in kidney transplant receipeints and promote the improvement of nursing quality.

Description of a research group
There were six team members in the research group, including two graduate nursing students, one associate professor of kidney transplant nursing research, one director of the kidney transplant unit, one head nurse of the kidney transplant unit, and one expert related to scale statistics. The main tasks of the research team included: review of relevant literature, preliminary construction of the evaluation index entry pool, selection of experts, preparation and distribution of expert correspondence forms, and collation and analysis of expert opinions.

Inclusion criteria of correspondence experts
Experts were selected by snowball sampling method in China. Inclusion criteria for experts were: (1) Nursing experts: Intermediate or above title, who have conducted research related to kidney transplantation and/or transitional care; 10 years or more in the field of nursing clinical/management/psychology/education; bachelor's degree or above; (2) Clinical medicine experts: above intermediate title, 10 years or more in kidney transplantation clinical work; master's degree or above; (3) All included experts were interested in supporting the study and could guarantee sustained attendance for the duration of the present study.

Development of evaluation indicators system
An initial effectiveness evaluation index system consisting of 5 primary indicators, 19 secondary indicators, and 61 tertiary indicators was developed through literature review and patient interviews.

Systematic literature reviews
The keywords "renal transplant*/kidney transplant*/ renal transplant recipients/kidney transplant recipients, transitional care/continuity of care/continuing nursing/ patient discharge planning/discharge planning/telemedicine/comprehensive care/multidisciplinary care" were searched in electronics database. Based on the systematic literature review, the Omaha system was used as the theoretical framework, and 42 questions in four major domains were referred to the Omaha problem classification system, which were combined with the effectiveness evaluation indexes and disease characteristics in the literature to form a preliminary pool of entries for evaluating the effectiveness of transitional care for kidney transplant recipients.

Patient interviews
A comprehensive understanding of kidney transplant recipients' experiences of transitional care and the indicators of transitional care effectiveness that transplant recipients consider important were obtained through interviews with transplant recipients, and the views of transplant recipients were considered in the construction of the indexes of transitional care effectiveness. Patients for this interview had to be 18 years or older. All patients provided their written informed consent in accordance with the Helsinki declaration.
Eleven selected patients were interviewed after their clinic follow-up. The outline of the interview included: (1) What is your current health status (physical symptoms, mental status and social activities)? (2) What are the indicators that concern you when you get the test report at the follow-up? (3) What changes have occurred in your habits, social activities, and perception of the disease after the transplant? (4) What are the issues that were important to you since your discharge from the hospital but were ignored by the medical staff?

Correspondence from experts
Expert correspondence form included 3 parts. First, the purpose, significance, theoretical basis and related concepts of present study; second, content consultation: consisting of indicators and scores, experts were invited to rate the importance of the entries, based on the Likert 5-point scale, from "unimportant" to "very important". Each level of indicators was left a blank column for additional description and recommendations; third, expert authority scale: including basic information of experts, questionnaire of judgment basis and questionnaire of content familiarity. The questionnaires were distributed by both email and on-site research. Experts of correspondence had to be 18 years or older.
In present study, indicators with a mean importance assignment > 4 and a coefficient of variation < 0.2 [14] were retained, and the indicators were selected by combining both expert opinions and discussions of the project team.
Statistical methods SPSS 16.0 software (SPSS Inc., Chicago, IL, USA) was used for data analysis. The general profile of the experts was expressed by frequency. The degree of expert opinion coordination was expressed as coefficient of variation (CV) and coordination coefficient (Kendall's W). The expert positivity coefficient was expressed by the questionnaire recall rate. The degree of expert authority was expressed by the expert authority coefficient (Cr), Cr = (familiarity coefficient + judgment basis coefficient)/2 [15]. Familiarity was categorized as unfamiliar (0.2 points), somewhat unfamiliar (0.4 points), somewhat familiar (0.6 points), very familiar (0.8 points), and proficient (1.0 points) [16]. Judgment score was assessed according a previous study [17]. Yaaph10.0 software (AHP program) was used to calculate the weight and consistency ratio (CR) of each index. The combination weight is calculated by applying the multiplicative method, that is, the product of the original weight of the indicator within the level and the combination weight of its higher-level indicators. For a level 1 indicator, the original weight is the combination weight.The weight of the indicator represents the relative importance of the indicator in the overall indicator system [18,19]. Generally, the more important the evaluation indicator is, the higher the weight value is.

Correspondence experts involved Basic information
Twenty-one experts were initially selected as correspondence experts, and after communication finally 19 experts participated in the study. These experts were from 10 tertiary hospitals and 1 higher education institution in 8 provinces. Demographic data on gender, age, work experience, academic degree, job title, and posts of participated experts had been summarized in Table 1.

Positive level of experts
In the first-round, twenty-one (n = 21) questionnaires were distributed and 19 were returned, with a recall rate of 90.48%. In the second-round, nineteen (n = 19) questionnaires were distributed and 19 were returned, with a recall rate of 100%.

Degree of authority of experts
The coefficient of expert familiarity (Cs) was 0.89 ± 0.14, the coefficient of judgment basis (Ca) was 0.90 ± 0.07, and the coefficient of authority (Cr) was 0.90 ± 0.09.

Results of expert consultation
In the first-round of expert consultation, the mean of the primary indicators was 4.26 to 4.84, and the coefficient of variation was 0.10 to 0.17; the mean of the secondary indicators was 3.89 to 4.95, and the coefficient of According to the selection criteria and experts' opinions, after the discussion of the research group, 2 indexes were revised in the first-level indexes. 2 indexes were added, 5 indexes were deleted, and 2 indexes were revised in the second-level indexes. 14 indexes were deleted, 5 indexes were added and 2 indexes were revised in the third-level indexes (Table 3).
After the second-round of consultation, the mean of primary indicators varied from 4.05 to 4.74 with coefficients of variation of 0.10 to 0.15; the mean of secondary indicators varied from 3.63 to 4.95 with coefficients of variation of 0.05 to 0.25; the mean of tertiary indicators varied from 3.95 to 5.00 with coefficients of variation of 0.00 to 0.21. After the research group's discussion, 2 indictors in the second-level indexes were added and 4 tertiary indicators were deleted ( Table 4). Details of the result of two rounds of correspondence refer to Additional file 1.
The final evaluation index system of 5 first-level indexes, 16 second-level indexes, and 48 third-level indexes for the evaluation of the effectiveness of kidney transplant recipients transitional care is shown in Table 5. The consistency test CR values for the total ranking of first-, second-, and third-level indexes ranged from 0.000 to 0.05, all < 0.1 [20].

Analysis of the scientific and reliability of the evaluation index system
The Omaha system is one of the standardized languages of nursing recognized by the American Nurses Association and includes three parts, which are an assessment component (Problem Classification Scheme), a care plan/services component (Intervention Scheme), and an evaluation component (Problem Rating Scale for Outcomes). Among them, the problem classification scheme includes a total of 42 common problems in four domains: environmental, psychosocial, physical and health-related behaviors. Wong et al. (2004) found that a health status record form of erminally ill patients established by a modified Omaha's problem classification scheme could assess the effectiveness of care from various aspects of environmental psychological and physiological behaviors [21]. Wei et al. (2019) formulated a transitional care evaluation system for breast cancer patients based on literature research, combined with Omaha's system, expert meetings, and through Delphi consultation [22]. The preliminary application showed the practicality and scientific validity of the system. Therefore, the Omaha system can be used for the construction of the evaluation index system and can reflect the problem more comprehensively, and the choice of the theoretical framework of this study is scientific. The scientific and disease-specific nature of the index system was fully reflected through an extensive literature review of literature related to transitional care interventions for kidney transplant recipients, extraction of effectiveness evaluation indicators, semi-structured interviews with transplant recipients, clarification of transplant recipients' experiences and expectations of transitional care, and supplementation of the index system content.
In this study, based on modified Delphi method, selected correspondence experts were from 8 provinces across China, including nurse leaders/nurses of kidney transplantation units, department vice directors/directors, and professors of colleges, who had unique insights into kidney transplantation transitional care and follow-up work, and had more in-depth studies on the Omaha system, with good representation of experts; the recall rates of the two rounds of correspondence questionnaires were 90.5% and 100%, indicating that the experts were more active in this study. The Cr value of the expert consultation was 0.90, reflecting the higher authority of the experts; the experts in the two rounds of consultation had significant agreement on the included indicators (all p < 0.05), and the consultation results were credible. In order to make the subjective data of expert judgment more scientific, hierarchical analysis was used to statistically process the expert judgment. Hierarchical analysis is a multi-criteria decision-making thinking that combines qualitative and quantitative wants, which could be compatible with the Delphi survey technique to solute problems in term of multi-level indicator systems or decision that can not be soluted by quantitatively [23]. In this study, the consistency test was used to assess the logical consistency of the judgment matrix and was expressed as the CR. It was generally considered that if CR < 0.1, the degree of inconsistency of the judgment matrix was within the accepted range, indicating that the weights of indicators at all levels were acceptable.

Content analysis of the evaluation index system
The final evaluation index system of the effectiveness of transitional care for kidney transplant recipients in this study included 5 first-level indexes, 16 second-level indexes, and 48 third-level indexes. The highest weight coefficients of 0.30 were assigned to the physiological and psychological domains, indicating that experts considered the physiological and psychological domains to be equally important in evaluating the effectiveness of transitional care in kidney transplantation.  found that the health outcomes of patients with chronic diseases were the most important evaluation index of the effectiveness of transitional care. The indexes of both physical and psychological domains constructed in present study were health outcomes, which are consistent with their findings [13].
In the physiological domains, the weight of secondlevel indexes "transplant kidney function" (weight = 0.13) and "infection status" (weight = 0.10) were the highest two indexes, indicating that these two indexs are critical to the physical health outcomes of transplant recipients. Transplant kidney function directly associated with the condition of the transplanted kidney and predict the survival of the transplanted kidney [24], therefore, maintaining transplanted kidney function was the primary objective of transitional care and transplant kidney function was the indicator of evaluating the effectiveness of transitional care. Transplant recipients were highly susceptible to infections due to the effects of immunosuppression. Studies had shown that approximately 80% of recipients had at least one infection within 1 year after kidney transplantation, with pulmonary and urinary tract infections being the main types of infections [25,26]. It is suggested that the education of transplant recipients on the recognition of early symptoms of infection and infection precautions in the transitional care should be strengthen.
The highest weight value (weight = 0.22) was assigned to the secondary indicator "positive psychological state" in the psychological domains, indicating that the experts considered the positive psychological state of the transplant recipient to be important. The postoperative psychological state of kidney transplant recipients was greatly influenced by the functional state of the transplanted organ in vivo and was prone to more psychological problems [27]. Along with the development of positive psychology, the guidance of positive emotions in transplant recipients should be strengthened in transitional care, and the development of positive psychological qualities in kidney transplant recipients should be emphasized to promote physical and mental health [28].
The weighting coefficient of the health behavior-related domains was 0.20, which play an important role in the evaluation of the effectiveness of transitional care. In present study, the health-related behavior domains of the Omaha problem classification system were adjusted and integrated with disease characteristics, and the results showed that the secondary indicators "medicationrelated adherence" (weight = 0.07) and "regular follow-up and self-monitoring" (weight = 0.07) were equally important in the health-related behavior domains. The regular long-term administration of immunosuppressive drugs and regular outpatient follow-up in kidney transplant recipients are the two main features that distinguish them from other surgical patients [29]. Kidney transplant recipients need to take immunosuppressive drugs for life, and the study has shown [30] that the longer the posttransplant period, the poorer the adherence to immunosuppressive drugs in kidney transplant recipients, and that poor adherence can lead to rejection and failure of the transplanted kidney. Therefore, improving medication adherence in transplant recipients is an important goal of transitional care and medication adherence is an important indicator of outcome evaluation. Long-term use of immunosuppressive drugs is a risk factor for new complications such as diabetes and pulmonary infections after transplantation [26,31], and regular follow-up and self-monitoring of transplant recipients should be emphasized to achieve early detection and diagnosis as well as early treatment. It was reminded that we should strengthen the education and training of transplant recipients' self-monitoring ability to improve their selfmanagement awareness and ability in the transitional care. The present study was combined the assessment of social health and the assessment of the environment, which was different from Omaha system. After discussion with experts and reviewing the literature, it was concluded that the first-level index of social environment could include the living environment, health care resource utilization, and social function [32,33]. In this study, the former secondary indicator "social activities" should have been removed according to the screening criteria. However, drug side effects and complications can impair a kidney transplant recipient's ability to participate in daily social and recreational activities, so social activity is a crucial outcome for kidney transplant recipients because it is a predictor of kidney transplant recipients' ability to return to daily life [34]. Two clinical care specialists were called for further consultation and agreed to retain and recommend modification to social function. This indicator was retained and renamed to "social function" in accordance with the experts' opinion.
The weighting coefficient of satisfaction was 0.06, indicating that experts considered satisfaction to be less important than other level 1 indicators, which may be related to the subjective nature of satisfaction. One expert stated that patient experience should be distinguished from quality of care and that the level of care should not be too dependent on the subjective feelings of patients.
In addition, present study was constructed as a gross indicator, and the appropriate indicators or weights should be adjusted for transplant recipients of different ages. For example, elderly transplant recipients have a higher incidence of post-transplant diabetes mellitus [35], lower medication adherence [36], and greater susceptibility to infection [37] compared to young and middle-aged transplant recipients, so the weight of indicator "blood glucose" may need to be higher for elderly transplant recipients, and the weight of indicators related to medical resource utilization, family and social support, and medication adherence may