A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study

Rationale & Objective: Adolescent and young adult kidney transplant recipients have a high risk of rejection related to suboptimal adherence. Multicomponent interventions improve adherence in controlled trials, but clinical implementation is lacking. We describe an initiative to reduce allo-graft rejection using evidence-based adherence promotion strategies. Study Design: Interrupted time series. Setting & Participants: Kidney transplant re-cipients cared for at Cincinnati Children's Hos-pital >= 1 year after transplant and taking >= 1 immunosuppressive medication(s) from 2014 through 2017. Quality Improvement Activities: The following interventions, collectively called MAPS (Medica-tion Adherence Promotion System), were imple-mented over 14 months: (1) adherence promotion training for clinical staff, 2) electronic health record-supported adherence risk screening, (3) systematic assessment of medication adherence barriers, (4) designation of specific staff to address adherence barriers, (5) shared decision-making with the patients to overcome adherence barriers, (6) follow-up evaluation to assess progress, and (7) optional electronic medication monitoring. Outcomes: Primary Outcome: Late acute rejec-tion. Process measures were conducted to assess barriers, identify barriers, and perform interventions. The secondary outcomes/balancing measures were de novo donor-specific antibodies (DSA), biopsy rate, and rejections per biopsy. Analytical Approach: Time series analysis using statistical process control evaluated patient-days between acute rejections as well as monthly rejections per 100 patient-months before and after implementation. To control for known rejection risk factors including changes in treatment and case mix, multivariable analyses were performed. Results: The monthly rejection rate fell from 1.61 rejections per 100 patient-months in the 26 months before implementation to 0.88 rejections per 100 patient-months in the 22 months after implementation. In the multivariable analysis, MAPS was associated with a 50% reduction in rejection incidence (incidence rate ratio, 0.50 [95% CI, 0.27-0.91]; P = 0.02). DSA and time since transplant (per each additional year) were also associated with rejection incidence (incidence rate ratio, 2.27 [P = 0.02] and 0.87 [P = 0.02], respectively). Limitations: Single-center study, and potential confounding by unmeasured variables. Conclusions: Clinical implementation of evidence-based adherence-promotion strategies was associated with a 50% reduction in acute rejection incidence over 2 years.

Automated summary

This study describes an initiative to reduce rejection risk in adolescent and young adult kidney transplant recipients through clinical implementation of evidence-based adherence promotion strategies. The results showed a 50% reduction in acute rejection incidence over 2 years after implementation.