*Purpose: In adolescents with a kidney transplant, non-adherence increases the risk of graft loss. Adherence promotion interventions improve adherence and rejection rates, but perceived cost remains a barrier to clinical implementation.

*Methods: We examined the cost-effectiveness of a single center medication adherence promotion system (MAPS) that was associated with a 45% reduction in rejection rates over a two-year period in a single center as a model to assess the cost-effectiveness of adherence promotion strategies in general. We used a Markov state transition decision model with a health care system perspective and a lifelong time horizon. Effectiveness was measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars.

*Results: In base-case analysis, post-transplant care with MAPS was more effective and less costly than usual care due to reduced acute rejection and increased graft survival with associated cost savings (Fig1). MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In sensitivity analyses, MAPS dominates usual care by being less costly and more effective so long as the RR for rejection is < 0.88. As efficacy declines (RR >0.88) the incremental cost-effectiveness ratio increases (Fig2). In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Strategies that reduce the risk of rejection by as little as 3% with similar cost are highly cost-effective. Interventions demonstrating greater reductions in rejection remain highly cost-effective as long as the start-up cost attributable to a single patient is less than $25,000 and the ongoing annual program cost per patient is less than $1,880 per year.

*Conclusions: This study describes a model that can be applied to study the cost-effectiveness of adherence promotion strategies. Given the significant cost and impact on quality of life associated with treatment of acute rejection and graft failure, even adherence promotion strategies that only modestly reduce acute rejection rates can have significant impact on health and quality of life at substantial cost-savings.

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