Nonadherence to immunosuppressives and treatment in kidney transplant: ADHERE BRAZIL Study

Marsicano-Souza, Elisa Oliveira; Colugnati, Fernando; Geest, Sabina De; Sanders-Pinheiro, Helady

doi:10.11606/s1518-8787.2021055002894

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Brasil

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Sumário

Original Article • Rev. Saúde Pública 55 • 2021 • https://doi.org/10.11606/s1518-8787.2021055002894 copy

Nonadherence to immunosuppressives and treatment in kidney transplant: ADHERE BRAZIL Study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To estimate the prevalence and variability of nonadherence to immunosuppressives and nonpharmacological treatment across kidney transplantation centers and two health access-disparate regions in Brazil.

METHODS

In a cross-sectional design, a random multistage sample of 1,105 patients was included, based on center transplantation activity (low/moderate/high) and region (R1: North/Northeast/Mid-West; and R2: South/Southeast). Nonadherence to immunosuppressives (implementation phase) was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS)^©. Self-report questionnaires assessed nonadherence to physical activity, smoking cessation, alcohol intake, and appointment keeping. We compared regions using the adjusted-χ² or t-test.

RESULTS

Most patients were men (58.5%), white (51.4%), and had a mean age of 47.5 (SD = 12.6) years. Regarding kidney transplantation centers, 75.9% were from R2 and 38.2% had low activity. The patients in R2 were older, white-majority, had more frequently steady partners, and received peritoneal dialysis. Nonadherence to immunosuppressives ranged from 11–65.2%; 44.5–90% to physical activity; 0–23.7% to appointment keeping; and 0–14% to smoking cessation. The total prevalence of nonadherence and by region (R1 versus R2) were: for immunosuppressives, 39.7% (44.9% versus 38.1%, p = 0.18); for smoking, 3.9% (1% versus 5%, p < 0.001); for physical activity, 69.1% (71% versus 69%, p = 0.48); for appointment keeping, 13% (12.7% versus 12%, p = 0.77); and for alcohol consumption, 0%.

CONCLUSION

Despite differences among centers and high variability, only the nonadherence to smoking cessation was higher in the region with greater access to kidney transplantation. We suppose that differences in healthcare access may have been overcome by other positive aspects of the post kidney transplantation treatment.

Patient Nonadherence; Medication Nonadherence; Kidney Transplant; Multicenter Study; Health Services Accessibility

Variable	All regions (N = 1105) %(n)	95%CI	N/NE/MW (N = 267) %(n)	95%CI	South/Southwest (N = 838) %(n)	95%CI	p*
Center characteristics
Number of beds of the transplant center hospital
Small/medium hospital (till 150 beds)	7.8 (86)	1.92–26.6	7.5 (20)	5.7–53.1	7.9 (66)	1.4–32.4	0.26
Large hospital (151 to 500 beds)	53.6 (592)	26.9–78.2	81.0 (216)	31.8–97.4	44.9 (376)	26.9–78.2
Special large hospital: > 500 beds	38.6 (427)	17.0–65.8	11.6 (31)	9.1–65.2	47.3 (396)	16–77.5
Multiprofessional team, Brazilian law Doctor+ nurse + nutritionist + psychologist + social worker (yes)	80.1 (886)	50.8–94	92.5 (247)	46.8–99.4	76.2 (639)	41.0–93.6	0.59
Clinical guidelines (yes)	94.0 (1039)	74.9–98.8	100.0 (267)	100.0	92.1 (772)	67.5–98.5	0.48
Continuous education directed to KT team (yes)	97.7 (1080)	82.0–99.7	100.0 (267)	100.0	97.0 (813)	76.6–99.6	0.61
Electronic medical records (yes)	53.8 (595)	25.6–79.7	29.6 (79)	4.8–77.5	61.6 (516)	25.0–88.5	0.28
Waiting room educational activities (yes)	47.9 (529)	21.3–75.6	57.7 (154)	12.6 – 92.7	44.7 (375)	16.0–77.4	0.68
Not satisfied with waiting room structure* (yes)	42.7 (427)	32.7–53.4	71.9 (192)*	54.6 – 84.4	33.4 (280)*	25.3–42.7	0.005
Not satisfied with the number of health professionals* (yes)	44.6 (493)	44.9–64.9	61.0 (163)*	52.2 – 69.2	39.6 (330)*	27.4–53.1	0.01
Difficulties in accessing the center by public transportation (yes)	13.7 (152)	6.2–27.9	13.8 (37)	6.2 – 27.9	13.7 (115)	6.3–27.2	0.69
Average total time of medical consultation
15 minutes	31.4 (348)	12.9–58.7	27.3 (73)	3.8–78.1	32.8 (257)	11.6–64.3	0.83
30 minutes	68.5 (757)	41.2–87.0	72.6 (194)	21.8–96.2	67.1 (563)	35.6–88.3
Not satisfied with the schedule system of the transplant center (yes)	22.9 (253)	13.9–35.4	31.2 (83)	19.0–46.6	20.3 (170)	9.6–37.9	0.27
Difficulties in scheduling appointments (yes)	10.3 (114)	6.2–16.8	16.2 (43)	6.4–35.4	8.5 (71)	4.3–16.1	0.23
Adequacy of the frequency of consultation* (yes)	86.4 (955)	83.0–89.5	87.9 (234)*	81.3–92.4	86.1 (721)*	81.9–89.5	0.02
Adequacy of time of consultation (yes)	94.8 (1,046)	93.1–96.1	93.2 (248)	89.2–95.8	95.3 (798)	93.6–96.6	0.18
Health system
Private insurance	23.4 (259)	19.3–28.0	18.7 (50)	12.3–27.3	24.9 (209)	20.4–30.0	0.18
Lab exams by public health system	90.3 (997)	83.6–94.5	83.5 (223)	75.8–89.1	92.6 (744)	84.5–96.2	0.06
Refill of immunosuppressives in another city	45.8 (506)	38.4–53.4	52.2 (139)	42.1–62.2	43.7 (367)	34.8–53.2	0.12
Immunosuppressives refill in a distant place*	54.0 (596)	46.3–61.5	66.9 (178)	62.9–70.6	49.9 (418)	40.5–59.3	0.002

Variable	All regions (N = 1105) %(n)	95%CI	N/NE/MW (N = 267) %(n)	95%CI	South/Southwest (N = 838) %(n)	95%CI	p*
Gender
Male	58.5 (647)	54.2–62.7	53.5 (143)	45.5–61.3	60.1 (504)	56.0–64.0	0.13
Race
White*	51.4 (586)	41.1–61.5	23.6 (63)	16.6–32.3	60.2 (505)	46.2–72.8	0.001
Age (years)	47.5 ± 12.6	–	44.1 ± 13.1	–	48.6 ± 12.2	–	0.001
Education level
Illiterate (0–4y)	7,8 (86)	4.9–12.0	6.3 (17)	3.2–12.0	8.2 (69)	4.7–13.9	0.15
Elementary school (4–8 years)	39.0 (431)	35.4–42.7	32.2 (86)	24.1–41.6	41.4 (345)	36.9–45.5
High school (> 8 to 11 years)	38.3 (423)	33.9–42.8	43.0 (115)	35.9–50.4	36.7 (308)	31.1–42.7
College (< 11 years)	14,9 (165)	12.3–17.9	18.3 (49)	15.2–22	13.8 (116)	10.8–17.5
Marital Status
Stable partner*	60.0 (662)	56.3–63.5	54.3 (144)	48.0–60.5	61.8 (518)	57.8–65.6	0.04
Not employed*	76.7 (848)	73.3–79.8	81.6 (218)	76.9–85.5	75.1 (630)	71.3–78.6	0.03
Family income
Until 1 reference wage	25.4 (281)	19.2–32.8	33.0 (88)	23.1 – 44.4	23.0 (193)	16.6–31.0	0.16
> 1 to 3 wages	52.7 (582)	46.4–58.8	50.9 (134)	43.3–57	53.5 (448)	45.8–61.0
> 3 to 5 wages	14.2 (157)	11.4–17.5	9.7 (26)	5.2–17.4	15.6 (131)	13.0–18.6
Up to 5 wages	7.6 (84)	4.9–11.4	7.1 (19)	4.8–10.3	7.7 (65)	4.5–13.0
Religion
Catholic	63.6 (703)	60.6–66.5	68.5 (183)	65.5–71.3	62.0 (520)	58.4–65.5	0.45
Protestant	26.0 (287)	23.3–28.7	24.3 (65)	19.2–30.2	26.4 (222)	23.3–29.8
Other	10.5 (116)	1.0–3.6	7.2 (19)	1.0–11.1	11.4 (96)	1.2–3.8
Pre-KT treatment*	93.0 (1028)	91.3–94.4	97.0 (259)	95.1–98.1	91.8 (769)	89.7–93.3	0.05
Hemodialysis	3.7 (40)	2.4–5.2	1.9 (5)	0.7–5.1	4.2 (35)	2.9–5.9
Peritoneal dialysis	3.3 (37)	2.2–5.1	1.1 (3)	0.3–4.3	4.0 (34)	2.5–6.4
Preemptive
Pre-transplantation treatment time (months)	40.4 ± 40.4	–	42.7 ± 39.8	–	39.6 ± 40.5	–	0.13
Post-transplant time (years)	6.2 ± 4.8	–	6.0 ± 4.9	–	6.2 ± 4.7	–	0.77
Type of donor
Deceased	65.2 (721)	55.8–73.5	72.2 (193)	54.2–85.1	63.0 (528)	52.9–72.1	0.32
Acute rejection
Yes	22.8 (2)	17.4–29.3	19.4 (52)	15.1–24.6	23.9 (198)	17.1–32.2	0.29
Last creatinine*	1.6 ± 0.83	–	1.4 ± 0.78	–	1.6 ± 0.84	–	0.001

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[1] Correspondence: Helady Sanders-Pinheiro Rua Benjamin Constant, 1044/1001 36015-400 Juiz de Fora, MG, Brasil E-mail: heladysanders@gmail.com