Risk Factors For Noncompliance

Frequently identified risk factors for noncompliance are shown in Table E7.1. Importantly, these risks may occur either early, late, or throughout the duration of followup. For example, a significant problem arising later posttransplant is the cost of the immunosuppressive medications. For almost all patients, medication is paid for (private insurance, Medicare, Medicaid) during the early post-transplant period. However, individual programs may have time limits or benefit maximums and if insurance coverage lapses, some recipients are unable to purchase necessary medications.

In a representative study, Frazier, et al., studied 241 kidney transplant recipients; about half reporting some degree of noncompliance.5 Of this population, recipients who were younger, female, unmarried, retransplanted, and with lower incomes more frequently reported medication noncompliance (p<.05). Similarly followup compliance was worse for those recipients who were unmarried, had lower income, non-diabetic, or with a longer time since transplant. Patients reporting higher stress and more depression, who coped with stress by using avoidant coping strategies, or who believed that health outcomes are beyond their control were also less compliant with both medications and follow-up. Conversely, the excellent outcomes with spousal renal transplants highlight the importance of loving concern and social support for the patient.6 Intuitively it seems very clear that significant medication noncompliance is unlikely to occur when a patient is eating breakfast and dinner with their donor.

Rudman, et al, noted that the best predictors of noncompliance were medication side effects, younger age, less education, and lack of comprehensive health insurance.7 In addition, using a survey guided by protection motivation theory, they found that patients more likely to be noncompliant felt less susceptible to negative outcomes, less able to follow treatment regimens, had less faith in the treatment's efficacy, and were relatively younger. In spite of recognizing these high-risk groups, to date, no studies have demonstrated effective prevention or intervention strategies.

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