Therapeutics

In hospitalized patients, an electronic alert for acute kidney injury did not differ from usual care Clinical impact ratings:

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Wilson FP, Shashaty M, Testani J, et al. Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial. Lancet. 2015;385:1966 –74.

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Question

*See Glossary.

In hospitalized patients, does an electronic alert for acute kidney injury (AKI) improve clinical outcomes?

†Information provided by author.

Methods Design: Randomized controlled trial (RCT). ClinicalTrials. gov NCT01862419. Allocation: Concealed.* Blinding: Blinded* (study personnel and outcome assessors). Follow-up period: 30 days. Setting: Tertiary care hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Patients: 2393 of 23 664 hospitalized patients ≥ 18 years of age (mean age 60 y, 56% men) who had ≥ 2 inpatient or outpatient {≥ 1 after hospital admission}† creatinine measurements and AKI (serum creatinine level ≥ 0.3 mg/dL [26.5 μmol/L] > the lowest value in the previous 48 h or ≥ 50% higher than the lowest value in the previous 7 d). Exclusion criteria were initial creatinine level ≥ 4.0 mg/dL (354 μmol/L), inability to determine the covering provider, admission to hospice or observation unit, or end-stage renal disease at admission. Intervention: Electronic alert sent once via text page to the covering provider (intern, resident, or nurse practitioner) and the unit pharmacist when AKI was detected by a computer algorithm, plus usual care (n = 1201) or usual care alone (n = 1192). 2400 patients were needed to detect a 1% decrease in deaths or dialysis, with a power of 90% (␣ = 0.05). Outcomes: Primary outcome was a composite ranking of death (highest rank), dialysis (second rank), and maximum change in creatinine from measurement at randomization (lowest rank; graded low to high) at 7 days. Secondary outcomes included the composite at 14 and 30 days and its components at 7, 14, and 30 days.

Sources of funding: National Institutes of Health and Penn Center for Healthcare Improvement and Patient Safety. For correspondence: Dr. F.P. Wilson, Yale University School of Medicine, New Haven, CT, USA. E-mail [email protected] 

Commentary Wilson and colleagues published the first randomized trial assessing an automated electronic alert for AKI. After the onset of AKI, adding the alert to usual care had no effect on kidney outcomes or processes of care compared with usual care alone. The trial has several features that may have limited the effectiveness of the alert. First, the AKI alert, a page sent to the care provider, was neither delivered within the hospital electronic record nor provided to care providers at the time and place of patient evaluation and management—these alert delivery criteria have been shown to improve effectiveness (1). Second, providers may have treated patients in both groups, potentially increasing recognition and care of AKI in the control group. A clusterrandomized design could have addressed this possibility. Third, alerts did not include clear recommendations for care. Future alerts could include treatment recommendations to help providers perform the interventions most likely to reduce the likelihood of worsening kidney function (2). Finally, the alerts were delivered without other interventions. Academic detailing and educational co-interventions could help change the behavior of health care providers in response to the alert (3). Rey R. Acedillo, MD Amit X. Garg, MD, PhD Western University London, Ontario, Canada

Patient follow-up: 100% (intention-to-treat analysis).

Matthew T. James, MD, PhD University of Calgary Calgary, Alberta, Canada

Main results Groups did not differ for the composite ranking outcome (P = 0.88), or for each component, at 7 (Table), 14, or 30 days.

Conclusion In hospitalized patients, an electronic alert for acute kidney injury added to usual care did not differ from usual care alone for death, dialysis, or serum creatinine.

References 1. Scheepers-Hoeks AM, Grouls RJ, Neef C, Ackerman EW, Korsten EH. Physicians' responses to clinical decision support on an intensive care unit comparison of four different alerting methods. Artif Intell Med. 2013;59:33-8. 2. National Clinical Guideline Centre (UK). Acute kidney injury: prevention, detection and management up to the point of renal replacement therapy. London: Royal College of Physicians (UK); 2013 Aug. www.ncbi.nlm.nih.gov /books/NBK247665/ (accessed 14 Apr 15). 3. Gjelstad S, Høye S, Straand J, et al. Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study). BMJ. 2013;347:f4403.

Electronic alert for acute kidney injury vs usual care in hospitalized patients‡ Outcomes

Event rates Alert

At 7 d

Usual care

RRI (95% CI)

Death

5.9%

5.1%

16% (⫺17 to 61)

Dialysis

7.2%

5.9%

23% (⫺9 to 67)

Median % increase (IQR) Creatinine§

0.0% (0.0 to 18)

0.6% (0.0 to 17)

P value 0.81

‡IQR = interquartile range; other abbreviations defined in Glossary. RRI and CI calculated from event rates in article. §Increase from randomization to the maximum achieved creatinine.

姝 2015 American College of Physicians

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ACP Journal Club

Annals of Internal Medicine

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16 Jun 2015

ACP Journal Club. In hospitalized patients, an electronic alert for acute kidney injury did not differ from usual care.

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