TY - JOUR
T1 - Electronic health record alerts for acute kidney injury
T2 - Multicenter, randomized clinical trial
AU - Perry Wilson, F.
AU - Martin, Melissa
AU - Yamamoto, Yu
AU - Partridge, Caitlin
AU - Moreira, Erica
AU - Arora, Tanima
AU - Biswas, Aditya
AU - Feldman, Harold
AU - Garg, Amit X.
AU - Greenberg, Jason H.
AU - Hinchcliff, Monique
AU - Latham, Stephen
AU - Li, Fan
AU - Lin, Haiqun
AU - Mansour, Sherry G.
AU - Moledina, Dennis G.
AU - Palevsky, Paul M.
AU - Parikh, Chirag R.
AU - Simonov, Michael
AU - Testani, Jeffrey
AU - Ugwuowo, Ugochukwu
N1 - Funding Information:
Funding: This work was supported by grants NIH P30DK079310 and R01 DK113191 to FPW. The funding sources had no involvement in study design; in collection, analysis, and interpretation of data; in writing of the manuscript; or in the decision to submit for publication. All authors have full access to all data in the study and take responsibility for the integrity of the data and the accuracy of its analysis.
Funding Information:
disclosure form at www.icmje.org/coi_disclosure.pdf and declare the following support for the submitted work: PMP is a consultant for Baxter and receives grant support from Dascena and BioPorto. AXG is supported by the Dr Adam Linton Chair in Kidney Health Analytics and a Clinician Investigator Award from the Canadian Institutes of Health Research. HF is a consultant for the Kyowa Kirin Corporation, and is the editor in chief of the American Journal of Kidney Disease. JT reports grants and personal fees from Sequana Medical, grants and personal fees from BMS, personal fees from Astra Zeneca, personal fees from Novartis, grants and personal fees from five laboratories, personal fees from Cardionomic, personal fees from Bayer, grants and personal fees from Boehringer Ingelheim, personal fees from MagentaMed, grants from Otsuka, personal fees from Renalguard, grants and personal fees from Sanofi, grants and personal fees from FIRE1, grants from Abbott, personal fees from WL Gore, and personal fees from Windtree therapeutics outside the submitted work. SGM receives grant support from the American Heart Association and the Patterson Trust Fund. CRP is on the advisory board of RenalytixAI and owns equity in the same; serves on the data and safety monitoring board of Genfit Pharma and is supported by NIH grants R01085757 and UO1DK-082185. MH has received consulting fees from Abbvie. DGM receives grant support from the NIH/NIDDK (K23DK117065). FPW reports grant support from NIDDK R01DK113191 and P30DK079210. Ethical approval: This research was approved by the Yale School of Medicine institutional review board (ID 1604017596) and the Bridgeport Hospital institutional review board (IDs 051802, 041801, 071808) under a waiver of informed consent. Data sharing: A deidentified participant dataset with an associated data dictionary can be found at https://doi.org/10.5061/ dryad.4f4qrfj95. The corresponding author affirms the honest, accurate, and transparent account of the reported research and that no important or relevant aspects of the study have been omitted. Any discrepancies from the study as originally planned have been explained. Dissemination to participants and related patient and public communities: There are no plans to disseminate the results of the research to individual study participants, but the results of this study will be disseminated as medical manuscripts. An associated press release will be made, and all manuscripts will be publicly available on PubMed Central. The study data have been made publicly available at the above website. Provenance and peer review: Not commissioned; externally peer reviewed. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Publisher Copyright:
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
PY - 2021/1/18
Y1 - 2021/1/18
N2 - AbstractObjective To determine whether electronic health record alerts for acute kidney injury would improve patient outcomes of mortality, dialysis, and progression of acute kidney injury. Design Double blinded, multicenter, parallel, randomized controlled trial. Setting Six hospitals (four teaching and two non-teaching) in the Yale New Haven Health System in Connecticut and Rhode Island, US, ranging from small community hospitals to large tertiary care centers. Participants 6030 adult inpatients with acute kidney injury, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. Interventions An electronic health record based "pop-up"alert for acute kidney injury with an associated acute kidney injury order set upon provider opening of the patient's medical record. Main outcome measures A composite of progression of acute kidney injury, receipt of dialysis, or death within 14 days of randomization. Prespecified secondary outcomes included outcomes at each hospital and frequency of various care practices for acute kidney injury. Results 6030 patients were randomized over 22 months. The primary outcome occurred in 653 (21.3%) of 3059 patients with an alert and in 622 (20.9%) of 2971 patients receiving usual care (relative risk 1.02, 95% confidence interval 0.93 to 1.13, P=0.67). Analysis by each hospital showed worse outcomes in the two non-teaching hospitals (n=765, 13%), where alerts were associated with a higher risk of the primary outcome (relative risk 1.49, 95% confidence interval 1.12 to 1.98, P=0.006). More deaths occurred at these centers (15.6% in the alert group v 8.6% in the usual care group, P=0.003). Certain acute kidney injury care practices were increased in the alert group but did not appear to mediate these outcomes. Conclusions Alerts did not reduce the risk of our primary outcome among patients in hospital with acute kidney injury. The heterogeneity of effect across clinical centers should lead to a re-evaluation of existing alerting systems for acute kidney injury.
AB - AbstractObjective To determine whether electronic health record alerts for acute kidney injury would improve patient outcomes of mortality, dialysis, and progression of acute kidney injury. Design Double blinded, multicenter, parallel, randomized controlled trial. Setting Six hospitals (four teaching and two non-teaching) in the Yale New Haven Health System in Connecticut and Rhode Island, US, ranging from small community hospitals to large tertiary care centers. Participants 6030 adult inpatients with acute kidney injury, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. Interventions An electronic health record based "pop-up"alert for acute kidney injury with an associated acute kidney injury order set upon provider opening of the patient's medical record. Main outcome measures A composite of progression of acute kidney injury, receipt of dialysis, or death within 14 days of randomization. Prespecified secondary outcomes included outcomes at each hospital and frequency of various care practices for acute kidney injury. Results 6030 patients were randomized over 22 months. The primary outcome occurred in 653 (21.3%) of 3059 patients with an alert and in 622 (20.9%) of 2971 patients receiving usual care (relative risk 1.02, 95% confidence interval 0.93 to 1.13, P=0.67). Analysis by each hospital showed worse outcomes in the two non-teaching hospitals (n=765, 13%), where alerts were associated with a higher risk of the primary outcome (relative risk 1.49, 95% confidence interval 1.12 to 1.98, P=0.006). More deaths occurred at these centers (15.6% in the alert group v 8.6% in the usual care group, P=0.003). Certain acute kidney injury care practices were increased in the alert group but did not appear to mediate these outcomes. Conclusions Alerts did not reduce the risk of our primary outcome among patients in hospital with acute kidney injury. The heterogeneity of effect across clinical centers should lead to a re-evaluation of existing alerting systems for acute kidney injury.
UR - http://www.scopus.com/inward/record.url?scp=85099807664&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85099807664&partnerID=8YFLogxK
U2 - 10.1136/bmj.m4786
DO - 10.1136/bmj.m4786
M3 - Article
C2 - 33461986
AN - SCOPUS:85099807664
SN - 0959-8146
VL - 372
JO - The BMJ
JF - The BMJ
M1 - m4786
ER -