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Chapter 31: Noncompliance in Liver Transplantation

Joaquin A. Cagliani; Andrés Ruhemann; Federico Piñero

INTRODUCTION

“…any organ that is rejected because of noncompliance is an organ that could have been given to someone else who may have died on the waiting list.”

–Laederach-Hofmann et al. (2000)

DEFINITION

  • Degree to which the person’s behavior does not correspond with the agreed recommendation from the health care provider.

FORMS AND FEATURES OF NONCOMPLIANCE

  • Clinical noncompliance

    • Clinically measurable events (e.g., rejection episodes, organ loss or death)

  • Subclinical noncompliance

    • Noncompliant patient who has not experienced a clinical adverse event yet

COURSE OF COMPLIANCE

  • Compliance declines over the course of time.

RISK FACTORS FOR NONCOMPLIANT BEHAVIOR

See Table 31-1 for a list of risk factors that can lead to noncompliant behavior.

TABLE 31-1Risk Factors
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TABLE 31-1 Risk Factors

Category

Description

Demographic and socioeconomic factors

  • African American race

  • Low SES

  • Family instability; family disequilibrium

  • Lack of peer groups/social isolation

  • Extreme anxiety and overprotection of the child by parents

  • Lack of social support from parents

  • Lack of family cohesion

  • Little parental supervision

  • Poor communication between parents and patient

  • Single-parent families

  • Cost of medication

Patient-related factors

  • Poor knowledge regarding medications

  • Poor understanding of the disease

  • Low self-esteem/poor body image

  • Forgetfulness

  • Striving toward independence

  • Social adjustment problems/poor social skills

  • Poor coping mechanism/denial

  • History of child abuse

  • Dropout from school, risk-taking behavior

  • Anger

  • Posttraumatic stress disorder

  • Psychological distress/depression

  • Previous nonadherence

  • Mental retardation

  • Busy lifestyle/hectic daily plans

Condition-related factors

  • Duration of illness

  • Substance abuse (e.g., alcohol)

  • Perception of vulnerability: lack of symptoms and the feeling of good health

  • Longer time posttransplant

Treatment-related factors

  • Cost of medication

  • Cosmetic side effects

  • Total number of medications

  • Number of medication doses per day

  • Complexity and chronicity of medication regimen

  • Taste of medication; pill size

Health care setting and health care provider related factors

  • Poor communication between health care provider, patient, and parents

  • Authoritarian communication style of health care provider

  • Poor didactic skills of health care provider

  • Poor knowledge of health care provider of medication nonadherence

  • Interference of follow-up with school/work

  • Anger/lack of trust of family toward health care providers

  • Lack of continuity of follow-up

  • Single-provider health care system (unidisciplinary care)

  • Increased waiting time to see provider/problems with accessibility of care

SES, Socioeconomic status.

AREAS OF POSTOPERATIVE NONCOMPLIANCE

Medication Noncompliance

  • Major cause of late acute rejection

  • Approximately 30.8% of patients were noncompliant with immunosuppressive therapy.

    • Fifteen percent to 25% in adult transplant recipients

    • Approximately 50% in adolescent transplant recipients

    • Reported 15.7% in pediatric transplant recipients

  • Young and from a lower socioeconomic group are more likely to be noncompliant

  • Measurement of medical compliance (Table 31-2)

  • Measurement of noncompliance variables (Table 31-3)

“…even the most clever immunosuppressive regime is ...

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