Objectives: Poor adherence to medication following pediatric liver transplantation remains a major challenge, with some estimates suggesting that 50% of adolescent liver transplant recipients exhibit reduced medication adherence. To date, no gold standard has emerged to address this challenge; however, system interventions are most likely to be successful. We sought to implement a system to identify and address adherence barriers in a liver transplant clinic. Methods: Using structured quality improvement methods, including multiple plan-do-study-act cycles, we developed a system to screen for patients at risk of poor adherence, identify patientand/or parent-reported barriers to adherence, and partner with patients to overcome identified barriers. We developed a process to track key outcomes, including the variability in tacrolimus trough levels and episodes of late acute cellular rejection. Results: The practice saw a total of 85 patients over 6 months, and about half were females. Over this period, the improvement team implemented this system-level process with high reliability (>90% of patients received the bundle of interventions). The most commonly identified adherence barrier by patients and caregivers was "forgetting." The second most commonly identified adherence barrier by patients was that the medication "gets in the way of their activities," whereas by caregivers, it was "difficulty swallowing pills." Discussion:We identified challenges and opportunities to screen for poor adherence and identify patient-and/or caregiver-reported barriers to immunosuppression adherence. Identifying such barriers and partnering with patients to overcome those barriers using patient-centered, barrier-specific interventions could improve long-term graft survival through improved medication adherence.

Graft-versus-host disease (GvHD) is a major complication of allogeneic hematopoietic stem cell transplantation affecting 30-60 % of patients despite prophylactic treatment. Acute GvHD (aGvHD) primarily affects the gut, the liver and/or the skin while chronic GvHD (cGvHD) typically resembles rheumatological or autoimmune disorders [1]. The standard for first-line therapy of acute and chronic GvHD are corticosteroids while the second-line treatment is less standardized and includes among others calcineurin inhibitors, mycophenolate mofetil (MMF), mTOR-and JAK2-inhibitors. Methotrexate (MTX) is an established agent for GvHD prophylaxis but not for GvHD treatment [2, 3].

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