Multilevel factors are associated with immunosuppressant nonadherence in heart transplant recipients: The international BRIGHT study

Kris Denhaerynck, Lut Berben, Fabienne Dobbels, Cynthia L Russell, Marisa G Crespo-Leiro, Alain Jean Poncelet, Sabina De Geest, BRIGHT study team, Maria G Crespo-Leiro, Sandra Cupples, Paolo De Simone, Albert Groenewoud, Christiane Kugler, Linda Ohler, Johan Van Cleemput, Laurent Sebbag, Magali Michel, Andrée Bernard, Andreas Doesch, Ugolino Livi, Valentina Manfredini, Vicens Brossa-Loidi, Javier Segovia-Cubero, Luis Almenar-Bonet, Carmen Segura Saint-Gerons, Paul Mohacsi, Eva Horvath, Cheryl Riotto, Gareth Parry, Ashi Firouzi, Stella Kozuszko, Haissam Haddad, Annemarie Kaan, Grant Fisher, Tara Miller, Maureen Flattery, Kristin Ludrosky, Bernice Coleman, Jacqueline Trammell, Katherine St Clair, Andrew Kao, Maria Molina, Karyn Ryan Canales, Samira Scalso de Almeida, Andrea Cotait Ayoub, Fernanda Barone, Michelle Harkess, Joanne Maddicks-Law, Kris Denhaerynck, Lut Berben, Fabienne Dobbels, Cynthia L Russell, Marisa G Crespo-Leiro, Alain Jean Poncelet, Sabina De Geest, BRIGHT study team, Maria G Crespo-Leiro, Sandra Cupples, Paolo De Simone, Albert Groenewoud, Christiane Kugler, Linda Ohler, Johan Van Cleemput, Laurent Sebbag, Magali Michel, Andrée Bernard, Andreas Doesch, Ugolino Livi, Valentina Manfredini, Vicens Brossa-Loidi, Javier Segovia-Cubero, Luis Almenar-Bonet, Carmen Segura Saint-Gerons, Paul Mohacsi, Eva Horvath, Cheryl Riotto, Gareth Parry, Ashi Firouzi, Stella Kozuszko, Haissam Haddad, Annemarie Kaan, Grant Fisher, Tara Miller, Maureen Flattery, Kristin Ludrosky, Bernice Coleman, Jacqueline Trammell, Katherine St Clair, Andrew Kao, Maria Molina, Karyn Ryan Canales, Samira Scalso de Almeida, Andrea Cotait Ayoub, Fernanda Barone, Michelle Harkess, Joanne Maddicks-Law

Abstract

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4-continent, 11-country cross-sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants-defined as any deviation in taking or timing adherence and/or dose reduction-was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS© ) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health-related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out-of-pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels.

Keywords: clinical decision-making; clinical research/practice; compliance/adherence; heart transplantation/cardiology; immunosuppression/immune modulation; social sciences.

© 2017 The Authors. American Journal of Transplantation published by Wiley Periodicals, Inc. on behalf of The American Society of Transplantation and the American Society of Transplant Surgeons.

Figures

Figure 1
Figure 1
The adapted ecological model of Bronfenbrenner et al6, 19, 20 (left) combined with patient‐level factors derived from the Integrative Model of Behavioral Prediction38 and empirical evidence (right)
Figure 2
Figure 2
Geographical location of participating BRIGHT centers and number of centers per country (N = 36). BRIGHT, Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation; HTx, heart transplant
Figure 3
Figure 3
Flowchart of heart transplant patient sample

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