Adherence promotion strategies cost-effective, improve graft rejection rates
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Adherence promotion strategies, such as the Medication Adherence Promotion System, proved to be cost-effective and improved rejection rates among adolescent kidney transplant recipients, according to a published study.
“To date, there are several randomized controlled trials that show systems to improve medication adherence can improve adherence in transplant patients, but they have not demonstrated a decrease in rejection rates — which is the primary purpose to improve medication adherence in transplant patients,” Charles D. Varnell Jr., MD, MS, assistant medical director of kidney transplantation from the division of nephrology and hypertension at Cincinnati Children’s Hospital Medical Center in Ohio, told Healio. “Further, people have identified that the primary barriers to implementing these systems in clinical practice are that we do not know if these systems are cost-effective. We used our own real-world implementation of a Medication Adherence Promotion System (MAPS) to decrease acute rejection rates in order to determine whether this type of intervention could save money while simultaneously improving the health of patients.”
In a simulation-based study, researchers evaluated adolescent patients after their first kidney transplant in the U.S. Researchers used a 16-state Markov transition decision analytic model to conduct a simulation of outcomes as patients transitioned across different health states every 3 months based on probabilistic events over time. Using a base case analysis, researchers measured the incremental cost-effectiveness ratio of MAPS vs. usual care.
Analyses revealed a 15-year-old kidney transplant patient could gain an average 0.32 quality-adjusted life-years from participating in MAPS. Additionally, this correlated with a decrease in acute rejection episodes from 63% to 43% during the patient’s life. Researchers identified the average lifetime cost of MAPS to be approximately $9,106 less per patients than usual care.
“We had a feeling beforehand that any reduction in rejection rates would make care more cost-effective given how much time and money goes into treating a rejection episode, and if the patient progresses to transplant failure, the cost of dialysis. However, we were impressed at how significant that finding was. In our sensitivity analyses, we explored how well our model adherence system – MAPS – performs under different hypothetical effectiveness and cost scenarios,” Varnell told Healio. “It turns out that MAPS saves money if it reduces rejection rates by as little as 12% and would still be considered ‘cost-effective’ if it reduces rejection rates by as little as 6%. From a cost standpoint, MAPS would still be ‘cost-saving’ for start-up costs up to $1.2 million in our population of 134 patients ($9,000/patient, 60 [times] higher than the actual estimated cost) and for ongoing costs up to $110,000 annually ($800/patient, [four times] higher than the actual estimated cost).”
According to the researchers, limitations of the study include results that may not be generalizable due to context-specific factors, such as quality improvement support and other environmental factors. Additionally, data were taken from pediatric and adolescent studies, but some came from adult literature. Therefore, data describing baseline rejection rates are lacking for pediatric transplant patients.
“Adolescents with a kidney transplant who lose their transplant due to suboptimal adherence have worse quality of life, a substantial reduction in their life expectancy and their care as a dialysis patient is more expensive than caring for a functioning transplant,” Varnell told Healio. “Showing that clinical systems to improve immunosuppression medication adherence are both more effective in reducing rejection rates than usual care and are less costly than usual care should encourage transplant programs to start utilizing adherence promotion systems in their clinics.”
Researchers noted that an effort is underway to evaluate the implementation and effectiveness of MAPS to kidney transplant programs in the Improving Renal Outcomes Collaborative.
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