Abstract
RATIONALE: Nonadherence to routine outpatient appointments (NApp) post kidney transplantation (KT) is a poorly studied health behavior associated with unfavorable outcomes. In the ADHERE BRAZIL Study, we previously reported a high prevalence of this behavior (12.7%). AIMS AND OBJECTIVE: This study aimed to identify the multilevel factors associated with NApp after KT. METHOD: A cross-sectional study, subproject of the ADHERE BRAZIL Study, was performed. We studied a randomized and multi-stage sample of 1105 patients from 20 transplant centers. Patients who missed one or more of the last five scheduled appointments were considered nonadherent. Multivariate analysis was performed using sequential logistic regression, evaluating 49 multilevel variables, according to the Ecological Model (patient, micro, meso, and macro levels). RESULTS: Most patients were male (58.5%), with a mean age of 47.6 ± 12.6 years. The independent factors associated with NApp were, at the patient level: age (OR 0.97; 95% CI 0.96-0.99; p = 0.001), more than 5 years after KT (OR 2.03; 95% CI 1.38-3.00; p < 0.001), and nonadherence to immunosuppressives (OR 2.41; 95% CI 1.66-3.50; p < 0.001); at the micro level (health professionals): higher scores on the team trust scale (0-100) (OR 0.98; 95% CI 0.95-1.00; p < 0.079), and at the meso level (KT center): frequent (monthly) consultations (OR 1.75; 95% CI 1.10-2.77; p < 0.018) and scheduling difficulties (OR 1.91; 95% CI 1.16-3.17; p < 0.011). CONCLUSION: This study is the first to examine the association of health system factors with missed appointments after KT. The identified patient factors allow us to recognize patients at risk for NApp. Modifiable variables at the health professional and KT center levels suggest targets for effective interventions aiming to reduce this behavior and improve outcomes. TRIAL REGISTRATION: ClinicalTrials.gov on 10/10/2013, NCT02066935.