Adherence-promotion strategies correlate with reduced allograft rejection
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Implementation of evidence-based adherence-promotion strategies correlated with a 50% reduction in acute allograft rejection for 2 years among kidney transplant recipients.
Further, donor-specific antibodies and time since transplant correlated with rejection incidence.
“Children, adolescents and young adults face many barriers to taking medication as prescribed. After an organ transplant, failure to address these barriers can lead to transplant rejection and organ failure,” David K. Hooper, MD, from the Cincinnati Children’s Hospital Medical Center in Ohio, and colleagues wrote. “In our kidney transplant clinic, we implemented an approach to help patients identify barriers to taking medication and to partner with clinical team members to overcome them.”
In an interrupted time series study, researchers assessed 130 kidney transplant recipients from Cincinnati Children's Hospital at least 1 year following the transplant and taking at least one immunosuppressive medication between 2014 and 2017.
A team gathered to identify barriers that keep patients from taking immunosuppression medications called the Medication Adherence Promotion System (MAPS). MAPS included the following:
- adherence promotion training for clinical team members;
- electronic health record-supported adherence risk screening;
- systematic assessment of barriers to taking medication;
- designation of specific team members responsible to partner with patients to address barriers;
- patient-centered shared decision-making to develop action plans;
- planned follow-up evaluation to assess progress and adapt action plans; and
- optional electronic adherence monitoring.
Researchers tested each intervention with patients with a primary outcome of biopsy-proven late acute rejection. Using statistical process control, researchers conducted a time series analysis to measure patient-days between acute rejections in addition to monthly rejections per 100 patient-months prior to and after implementation. Multivariable analyses allowed researchers to control for known rejection risk factors.
Analyses revealed the monthly rejection rate declined from 1.61 rejections per 100 patient-months in the 26 months prior to implementation to 0.88 rejections per 100 patient-months during the 22 months following implementation. Similarly, MAPS correlated with a 50% decline in rejection incidence. Researchers also identified a link between donor-specific antibodies and time since transplant with rejection incidence.
“MAPS was fully integrated as standard care in our clinic and was applied to all patients on immunosuppression, thus demonstrating its feasibility in a real-world setting,” Hooper and colleagues wrote. “Using a system/population-based analysis with statistical process control, we observed a 45% reduction in late acute rejection rate within months of complete MAPS implementation. This reduction was sustained for nearly 2 years, despite no significant change in kidney biopsy rates.”
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