Effect of Clinical Decision Support With Audit and Feedback on Prevention of Acute Kidney Injury in Patients Undergoing Coronary Angiography

Abstract

ImportanceContrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes.ObjectiveTo determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI.Design, Setting, and ParticipantsA stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020.InterventionsDuring the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention.Main Outcomes and MeasuresThe primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models.ResultsOf the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 [SD, 10.7] years; 1384 were women [32.0%]) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 [SD, 10.8] years; 1151 were women [33.0%]). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, −2.3% [95% CI, −0.6% to −4.1%]; odds ratio [OR], 0.72 [95% CI, 0.56 to 0.93]; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, −12.0% [95% CI, −14.4% to −9.4%]; OR, 0.77 [95% CI, 0.65 to 0.90]; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, −15.8% [95% CI, −19.7% to −12.0%]; OR, 0.68 [95% CI, 0.53 to 0.87]; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events.Conclusions and RelevanceAmong cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation.Trial RegistrationClinicalTrials.gov Identifier: NCT03453996

Quality and safety in the literature: January 2023

“…In their stepped-wedge, cluster randomised clinical trial, James and colleagues sought to understand the effect of a combined quality improvement intervention, focused on CI-AKI prevention strategies, on rates of AKI among patients undergoing non-emergency coronary angiography in Alberta, Canada 30. The intervention was aimed at cardiologists performing coronary angiography and percutaneous coronary intervention and included education, computerised clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets and audit and feedback.…”

Clinical Decision Support to Prevent Acute Kidney Injury After Cardiac Catheterization

“…The intervention outlined in the study by James et al was consistent with study design principles from the burgeoning field of implementation science . The initial educational session likely promoted clinician awareness and garnered buy-in for the intervention .…”

“…Case studies of successful clinical decision support interventions can provide valuable information on best practices, including institutional and policy environments that facilitate this type of innovation. In this issue of JAMA , James et al report a pragmatic, cluster randomized clinical trial combining education, clinical decision support–based algorithms, and scheduled audit and feedback to study the effect of this multifaceted intervention on the development of acute kidney injury (AKI) after intravenous contrast administration during cardiac catheterization.…”

“…To optimize practice, James et al leveraged published studies that had demonstrated improved clinical outcomes, including the POSEIDON (Prevention of Contrast Renal Injury With Different Hydration Strategies) trial, which showed that in patients with chronic kidney disease and 1 or more comorbidities, fluid administration guided by left ventricular end-diastolic pressure was associated with a reduced risk of AKI. Another controlled study aimed at initiation of kidney replacement therapy for patients with AKI, which was based on a similar rationale of variation in clinical practice influencing outcomes, showed that implementation of a point-of-care algorithm (122 patients) compared with a sham control (102 patients) was associated with reduced intensive care unit length of stay, hospital length of stay, and use of kidney replacement therapy in cases of physician-perceived treatment futility.…”

System-Based Solutions to Minimizing Nephrotoxin-Induced Acute Kidney Injury

“…Computer-based clinical decision support is one attractive strategy that has been leveraged in prior studies to prompt physicians to stop nephrotoxic medications after AKI has been identified, 3 yet broad implementation of systematic strategies for preventing and managing AKI has shown variable success. [4][5][6] The Nephrotoxic Injury Negated by Just-In-Time Action (NINJA) initiative is one impressive example of a focused clinical decision support intervention that has been rigorously developed, implemented, and evaluated to prevent harm due to drug-associated AKI in children. 7,8 NINJA is a quality improvement initiative that originated at the Cincinnati Children's Hospital Medical Center.…”