A quality improvement initiative for achieving target tacrolimus concentration in renal transplant recipients: A...

Tacrolimus is a cornerstone immunosuppressive agent in solid organ transplantation due to its efficacy in preventing rejection. Achieving optimal tacrolimus levels remains challenging and limited studies have explored quality improvement (QI) initiatives aimed at optimizing tacrolimus trough levels. We conducted a QI initiative at Taichung Veterans General Hospital targeting tacrolimus level optimization in renal transplant recipients between January 2015 and January 2019. This multifaceted intervention included: physician reminders integrated into the Electronic Health Information System (EHIS) to monitor trough levels and variability, patient engagement through a mobile application displaying immunosuppressant levels, and automated tacrolimus concentration measurement to reduce ordering errors. Outcomes were descriptively evaluated before and after the interventions, including measurement accuracy, biopsy-proven acute rejection (BPAR) rates, and intrapatient variability (IPV), without formal statistical comparison. The implementation of automated tacrolimus measurement eliminated ordering errors, leading to an estimated cost saving of $78,911.3 over 2 years. A numerical decrease in BPAR incidence was observed, from 9% pre-intervention to 0% post-intervention. Tacrolimus intrapatient variability (IPV) also showed a decreasing trend, from 26.45% in 2019 to 18.7% in 2022. Physician reminders and patient engagement interventions contributed to improved monitoring but had a less pronounced impact on acute rejection rates. This study describes a structured QI initiative, including the automation of tacrolimus concentration measurements, and its association with improvements in therapeutic drug monitoring processes in renal transplant recipients. These findings suggest a potential role for mistake-proofing mechanisms in enhancing measurement accuracy and contributing to cost savings. Observed changes in rejection rates were descriptive and should be interpreted with caution given the small number of events.