医疗预约不依从对肾移植移植物结局的影响。
The Impact of Health Care Appointment Non-Adherence on Graft Outcomes in Kidney Transplantation.
作者信息
Taber David J, Fleming James N, Fominaya Cory E, Gebregziabher Mulugeta, Hunt Kelly J, Srinivas Titte R, Baliga Prabhakar K, McGillicuddy John W, Egede Leonard E
机构信息
Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, S.C., USA.
出版信息
Am J Nephrol. 2017;45(1):91-98. doi: 10.1159/000453554. Epub 2016 Dec 2.
BACKGROUND
Non-adherence to medication is a well-studied and known cause of late allograft loss, but it is difficult to measure and prospectively monitor. The aim of this study was to assess if appointment non-adherence was correlated with medication non-adherence and a predictor of graft outcomes.
METHODS
This was a longitudinal cohort study that used the National United States Renal Data System and veterans affairs health records data with time-to-event analyses conducted to assess the impact on graft and patient survival.
RESULTS
The number of transplants that were included in the analysis was 4,646 (3,656 with complete records); 14.6% of patients had an appointment no show rate of ≥12% (non-adherence). Appointment and medication non-adherence were highly correlated and both were significant independent predictors of outcomes. Those with appointment non-adherence had 1.5 times the risk of acute rejection (22.0 vs. 14.7%, p < 0.0001) and a 65% higher risk of graft loss (adjusted hazards ratio (aHR) 1.65, 95% CI 1.38-1.97, p < 0.0001). There was a significant interaction between appointment and medication non-adherence; those with appointment and medication non-adherence were at very high risk of graft loss (aHR 4.18, 95% CI 3.39-5.15, p < 0.0001), compared to those with only appointment non-adherence (aHR 1.39, 95% CI 0.97-2.01, p = 0.0766) or only medication non-adherence (aHR 2.44, 95% CI 2.11-2.81, p < 0.0001).
CONCLUSION
These results demonstrate that non-adherence to health care appointments is a significant and independent risk factor for graft loss.
背景
不坚持服药是同种异体移植后期失败的一个经过充分研究且为人所知的原因，但难以进行测量和前瞻性监测。本研究的目的是评估预约不依从是否与药物治疗不依从相关，以及是否为移植结局的一个预测因素。
方法
这是一项纵向队列研究，使用了美国国家肾脏数据系统和退伍军人事务部的健康记录数据，并进行了事件发生时间分析，以评估对移植和患者生存的影响。
结果
纳入分析的移植例数为4646例（3656例有完整记录）；14.6%的患者预约未就诊率≥12%（不依从）。预约不依从和药物治疗不依从高度相关，且二者均为结局的显著独立预测因素。预约不依从的患者发生急性排斥反应的风险是前者的1.5倍（22.0%对14.7%，p<0.0001），移植失败风险高65%（调整后风险比[aHR]1.65，95%置信区间[CI]1.38 - 1.97，p<0.0001）。预约不依从和药物治疗不依从之间存在显著交互作用；与仅预约不依从（aHR 1.39，95% CI 0.97 - 2.01，p = 0.0766）或仅药物治疗不依从（aHR 2.44，95% CI 2.11 - 2.81，p<0.0001）的患者相比，预约和药物治疗均不依从的患者移植失败风险极高（aHR 4.18，95% CI 3.39 - 5.15，p<0.0001）。
结论
这些结果表明，不遵守医疗预约是移植失败的一个重要独立危险因素。
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