*Purpose: To study the effect of implementing a Medication Adherence Promotion System (MAPS) on acute rejection (AR) rates in 9 pediatric kidney transplant (KT) programs.

*Methods: Time series analysis of AR and biopsy rates across 9 IROC centers who have begun clinical implementation of MAPS: a bundle of evidence-based strategies to identify patients at risk for rejection and address patient/caregiver identified immunosuppression adherence barriers. AR and biopsy rates for all pts > 1-yr post-KT (n=558, 64% male, median age 15y) were analyzed from 1/2018 through 10/2020 using statistical process control u-charts. Centerline and 3 standard deviation control limits were calculated from baseline data and adjusted when special cause was met according to established standards. Charts were annotated with the date each center started bundle interventions.

*Results: 130/266 (49%) pts identified at least 1 adherence barrier – most commonly: forgetting to take the medication, hate the taste, and side effects. Baseline rejection rate in the nine centers was 0.94 per 100 patient months, special cause was first noted 8/2019 – the rejection rate decreased to 0.53 rejections per 100 patient months. Baseline biopsy rate in the centers was 6.39 biopsies per 100 patient months, special cause was first noted 8/2019 – the biopsy rate decreased to 3.03 biopsies per 100 patient months. Whereas rejection and biopsy rates both decreased by about 50%, there was no change in the percentage of biopsies with rejection, suggesting the decrease in rejection rate was not due to ascertainment bias (i.e. simply performing less biopsies).

*Conclusions: The spread of a clinical system to identify and address adherence barriers across diverse clinical settings is preliminarily associated with decreased rates of acute rejection and biopsies.

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