Fatores associados a não aderência à frequência nas consultas ambulatoriais em transplantados renais no Brasil: resultados do estudo multicêntrico ADERE Brasil

Abstract

Kidney transplantation (KT) is recognized as the most effective replacement therapy for suffering from chronic kidney disease patients in functional failure phase. However, the effectiveness of this treatment substantially depends on the adherence of the several aspects of post KT treatment. Non-adherence to outpatient appointments (NApp) is a risky behavior, associated with adverse outcomes, such as acute rejection and worse graft survival. The ADHERE Brazil study reported a high prevalence of NApp of 12.7%. Objective: The present study aims to identify multilevel factors [patient, micro (health professional), meso (health service) and macro (health system)] associated with NApp after KT. Method: We did a crosssectional study, as part of the ADHERE Brazil project, using a random sample of 1,105 patients from 20 KT centers selected by convenience criteria. The selection covered a comprehensive representation of the country's regions and transplant activitie. Adherence to appointments was assessed by a self-report questionnaire, based on the recall of the last five appointments. Patients who missed one or more of these appointments were considered non-adherent. We performed sequential multivariate analysis by generalized estimated equations (GEE) and linkage function to assess the association among multilevel variables, following the ecological model, and the NApp as outcome. Results: The studied patients were predominantly male (58.5%), white (51.3%) and had a mean age of 47.6 + 12.6 years. The majority of patients reported elementary school education (39.1%), stable partner (60.1%), and family income of 1 to 3 reference salaries (52.8%). They were predominantly on hemodialysis before KT (93%), time post-KT was less than 5 years (51.13%) and received grafts from deceased donors (65.2%). Most of them did not live in the same city of the KT center (68.9%), and did not have private insurance (76.6%).The independent factors associated with NApp at the patient level: age (OR 0.97; CI 0.96-0.99; p=0.001), more than 5 years after KT (OR 2.03; CI 1.38-3.00; p<0.001), and non-adherence to immunosuppressives (OR 2.41; CI 1.66-3.50; p<0.001); at the micro level (health professionals): team trust scale (OR 0.98; CI 0.95-1.00; p<0.079), and at the meso level (KT centre): frequent (monthly) consultations (OR 1.75; CI 1.10-2.77; p<0.018) and difficulty scheduling (OR 1.91; CI 1.16-3.17; p<0.011). Conclusions: In this first study evaluating multilevel factors associated with NApp, we found beyond the patient level, associations with KT health team and practice patterns variables. These findings suggest the interventions to decrease NApp in KT should include to changes in the care model strategies focused on the quality of team-patient relationship, and dynamic of clinical practice of KT centers, aiming to reduce unfavorable outcomes.