Factors Associated With Nonadherence to Appointments Among KT Recipients
The optimal treatment for patients with kidney failure due to advanced chronic kidney disease is kidney transplantation. Transplantation provides improved quality of life, a reduction in comorbidities, and lower healthcare costs compared with dialysis. Kidney transplant (KT) recipients require long-term management after transplantation, including immunosuppressive therapy and strategies to address multiple risk factors, preexisting comorbidities, and conditions that arise after transplantation.
Patient adherence to treatment after transplantation is closely tied to effective self-care. That includes medication use, regular physical exercise, adherence to diet, cessation of smoking and alcohol use, laboratory assessments, and clinical consultations. Nonadherence to immunosuppressive regimens is a risk factor for worse graft survival, greater patient morbidity, and higher healthcare costs.
Few data are available regarding the association between nonadherence to routine outpatient appointments (NApp) and unfavorable outcomes. The cross-sectional ADHERE BRAZIL study explored the prevalence and factors associated with nonadherence to immunosuppressive regimens and other health behaviors of KT recipients. Roberta Lopes Karlburger and colleagues conducted a subanalysis of data from that study to identify multilevel factors (patient, healthcare professional, health service, health policy) associated with NApp.
The study was conducted at 20 Brazilian transplant centers representing the geographic areas of Brazil (North, Northwest, Midwest, South, and Southeast) and considering the activity of the centers (number of transplants per year). Participants were randomly selected from patients attending routine visits at the centers. Eligible patients were 18 years of age or older, had undergone transplant more than 1 year ago, were treated with blood-measurable immunosuppressives, and signed an informed consent form.
Forty-nine variables were included in the study: 29 at the patient level, two at the healthcare professional level (micro level), 16 at the KT center service level (meso level), and two at the health system level (macro level). Researchers assessed these variables through multivariate analysis using sequential logistic regression.
A total of 1,105 patients were included in the study. Their mean age was 47.6 years, 58.5% were male, and 51.3% were White. Patient characteristics included elementary school education (39.1%), having a stable partner (60.1%), active employment (23.3%), and family income of one to three reference wages, the Brazilian minimum wage (52.8%). The main cause of chronic kidney disease was glomerulonephritis (28.6%). Ninety-three percent of participants were receiving hemodialysis before kidney transplantation. The mean time since transplantation was less than 5 years for 51.13% of participants, and 65.2% of the transplants were from a deceased donor. Most recipients (69.1%) were physically inactive, 3.9% were smokers, and 39.7% were classified as nonadherent to immunosuppression. Most did not live in the city of their transplant center (68.9%) or have private insurance (76.6%).
The prevalence of NApp was 12.7%. The researchers performed a bivariate descriptive analysis of the multilevel factors related to NApp for both adherent and nonadherent patients. They selected 13 variables (nine at the patient level, one at the healthcare professional level, and three at the healthcare organization level) to be included in the multiple model. Results of the final model identified socioeconomic factors (age), treatment-related factors (time since KT >5 years), and behavioral factors (nonadherence to immunosuppression) as independent factors associated with NApp at the patient level.
At the healthcare professional level, an association was seen between trust in the healthcare team and NApp. At the health center level, an association was observed between NApp and the frequency of consultations and difficulty in scheduling.
For each year of age, there was a 3% reduction in the likelihood of being less adherent to consultations (odds ratio [OR], 0.97; 95% CI, 0.96-0.99). Nonadherence to consultations was twice as likely among patients who had undergone transplant more than 5 years ago (OR, 2.03; 95% CI, 1.38-3.00). Patients who were nonadherent to immunosuppression were nearly 2.5-fold more likely to be nonadherent to consultations (OR, 2.41; 95% CI, 1.66-3.50).
For the healthcare team–related variables, a 2% reduction in the likelihood of being nonadherent to consultations was seen with each point increase in the trust scale (OR, 0.98; 95% CI, 0.95-1.00). For variables related to the KT center, patients with frequent consultations (monthly) were 75% more likely to be less adherent to consultations (OR, 1.75; 95% CI, 1.10-2.77). Patients with scheduling difficulties were nearly twice as likely to be nonadherent to consultations (OR, 1.91; 95% CI, 1.16-3.17).
The authors cited some limitations to the study findings, including the cross-sectional design, which limited the ability to make causal inferences from the observed associations; the use of a self-report questionnaire, which may have underestimated NApp compared with checking attendance at appointments in the electronic medical records of patients; and the use of secondary data, which may have allowed variables associated with NApp to be overlooked.
In conclusion, the researchers wrote, “This study was the first to evaluate the multilevel factors associated with NApp after KT. The results showed the association with variables at the micro and meso levels and therefore beyond the patient level, suggesting the need for a care model that focuses on the quality of the team-patient relationship as well as on the dynamics in the clinical practices of transplant centers to reduce the behavior of NApp and its undesirable outcomes.”
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