*Purpose: We aimed to identify care processes and structures that are independently associated with higher medication adherence among adolescent and young adult transplant recipients.

*Methods: We conducted a prospective, observational cohort study of 270 prevalent kidney, liver, and heart transplant recipients 14-25 y followed in 1 of 14 paediatric or 14 adult transplant programs across Canada. All patients were >3 months post-transplant and >2 months post-discharge. Patients were classified as adherent or non-adherent at baseline, 3mo and 6 mo based on the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS); adherent patients had missed no immunosuppressive doses in the prior 4 weeks. Transplant program directors and nurses at each program completed questionnaires regarding organization of care, composition of the team, and care processes/protocols. Program-level factors that varied substantially across programs were considered in the models as potential independent correlates of higher adherence. We used mixed models, with program as a random effect, accounting for clustering by program and for repeated adherence measures within patients, to identify independent correlates of adherence. Models were adjusted for non-modifiable patient-level factors that may act as confounders due to their association with adherence (age, sex, time since transplant, donor source, number of meds, primary caregiver [self vs. other], who prepares meds).

*Results: There were 66 kidney, 16 liver, and 17 heart recipients in paediatric programs, and 118 kidney, 42 liver and 11 heart recipients in adult programs. The median age was 20.3 y (IQR 17.2-23.2); median time since transplant 5 y (IQR 2.1-10.7); 119 (44%) were female. At baseline, 71.5% were adherent. Factors significantly independently associated with greater adherence were greater minimum prescribed frequency of routine blood work for those >3 y post-transplant, routine reminders for blood work and greater average time spent with nurse (Table 1). Male sex (0.52 [0.36,0.75]) and longer time since transplant (0.95 [0.92,0.99]) were associated with significantly poorer adherence. Living donor source was associated with significantly better adherence (2.24 [1.51,3.33]).

*Conclusions: Program-level factors related to the ‘culture of care, including intensity of routine follow-up and support to patients, are associated with medication adherence. This suggests that interventions at the program level may support better adherence.

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