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A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study
David K Hooper1, Charles D Varnell1, Kristin Rich2
1Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Insights
Implementing a Medication Adherence Promotion System (MAPS) in adolescent and young adult kidney transplant recipients significantly reduced allograft rejection by 50%. This evidence-based strategy improved adherence and patient outcomes, addressing a critical need in post-transplant care.
Area of Science:
- Nephrology
- Transplantation
- Adolescent Medicine
Background:
- Adolescent and young adult kidney transplant recipients face high rejection rates due to poor medication adherence.
- Multicomponent interventions show promise in trials but lack clinical implementation.
- This study addresses the gap by implementing evidence-based adherence strategies.
Purpose of the Study:
- To describe the implementation of a Medication Adherence Promotion System (MAPS).
- To evaluate the impact of MAPS on reducing allograft rejection in kidney transplant recipients.
- To assess the effectiveness of adherence promotion strategies in a clinical setting.
Main Methods:
- An interrupted time series design was used.
- Interventions included staff training, EHR-supported screening, barrier assessment, dedicated adherence staff, shared decision-making, follow-up, and optional electronic monitoring.
- Statistical process control and multivariable analyses evaluated rejection rates before and after MAPS implementation.
Main Results:
- The monthly rejection rate decreased from 1.61 to 0.88 per 100 patient-months post-MAPS.
- Multivariable analysis showed MAPS was associated with a 50% reduction in rejection incidence (IRR, 0.50; P=0.02).
- De novo donor-specific antibodies (DSA) and time since transplant were also significant factors in rejection incidence.
Conclusions:
- Clinical implementation of evidence-based adherence promotion strategies (MAPS) significantly reduced acute rejection incidence by 50% over two years.
- The findings support the integration of structured adherence programs into routine transplant care.
- Further research should address potential confounding variables in single-center studies.
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 allograft rejection using evidence-based adherence promotion strategies.
Study Design:
Interrupted time series.
Setting & Participants:
Kidney transplant recipients cared for at Cincinnati Children's Hospital ≥ 1 year after transplant and taking ≥1 immunosuppressive medication(s) from 2014 through 2017.
Quality Improvement Activities:
The following interventions, collectively called MAPS (Medication Adherence Promotion System), were implemented 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 rejection. 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.
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