A pragmatic randomized controlled trial comparing pathway-based versus usual care in community-acquired acute kidney injury

Abstract

Clinical pathways have shown conflicting evidence in improvement of several patient-centered outcomes across different clinical settings. However, the effectiveness of clinical pathway in management of acute kidney injury (AKI) has not been reported. Therefore, we aimed to assess the length of hospital stay (LOS) and patient-centered outcomes in community acquired AKI and compared pathway care (PC) versus usual care (UC). The CHAMP-Path AKI Trial is a pragmatic, parallel, single-blind randomized controlled trial. Physicians were randomized to provide either UC or PC. Patients were randomized through a computer-generated sequence. Allocation was concealed. Patients presenting to the emergency department with AKI and hemodynamic stability, who were over 14 years with a serum creatinine greater than 1.5 times the baseline were eligible. Patients with chronic kidney disease stages 4 or 5, kidney transplantation recipients, those admitted with obstructive uropathy, suspected glomerular or interstitial disease, and pregnant women were excluded. Thirty-eight patients were enrolled from March 2012 to December 2013. The primary outcome was LOS. Secondary outcomes included: 30-day readmission, in-hospital mortality, determinants of LOS, and patient-centered outcomes. Eighteen patients were randomized to PC, and 20 to UC. Baseline characteristics were comparable in both groups. Using an intention-to-treat analysis, the median LOS was 4.96 [interquartile range (IQR) 6.57] and 4.80 days (IQR 6.84) for PC and UC, respectively (P = 0.770). Of the five readmissions, none were for AKI. No in-hospital mortality was reported. The CHAMP-Path AKI pragmatic trial demonstrated that PC was not different than UC in reducing LOS. There was no difference in 30-day re- admission, in-hospital mortality, and patient-centered outcomes.

Pharmacists as Interprofessional Collaborators and Leaders through Clinical Pathways

“…Furthermore, the study method and collaboration of pharmacy with the multidisciplinary team were presented at other international research forums, such as The Principles and Practice of Clinical Research course in Sao Paulo, Brazil in 2011 offered by Harvard T H Chan School of Public Health and the Global Conference of the American College of Clinical Pharmacy, CA, United States in 2015. Finally, to date, two papers reporting CHAMP-Path studies were published with the coordinating clinical pharmacist as the leading author or co-author [ 22 , 23 ]. In the acute kidney injury study, the primary outcome of median length of stay (LOS) was 4.96 days (interquartile range of 6.57) for the pathway care compared to 4.8 days (interquartile range of 6.84 days) for the usual care ( p = 0.8).…”

“…In the acute kidney injury study, the primary outcome of median length of stay (LOS) was 4.96 days (interquartile range of 6.57) for the pathway care compared to 4.8 days (interquartile range of 6.84 days) for the usual care ( p = 0.8). Secondary outcomes of 30-day readmission and in-hospital mortality were also not statistically different [ 23 ]. Preliminary findings of unpublished data demonstrated that heart failure and venous thromboembolism showed a significant reduction in primary outcome of LOS and further data analysis for the findings of the studies is ongoing.…”