Early, Individualized Recommendations for Hospitalized Patients With Acute Kidney Injury: A Randomized Clinical Trial.

JAMA Pub Date : 2024-10-25 DOI:10.1001/jama.2024.22718
Abinet M Aklilu,Steven Menez,Megan L Baker,Dannielle Brown,Katie K Dircksen,Kisha A Dunkley,Simon Correa Gaviria,Salia Farrokh,Sophia C Faulkner,Charles Jones,Bashar A Kadhim,Dustin Le,Fan Li,Amrita Makhijani,Melissa Martin,Dennis G Moledina,Claudia Coronel-Moreno,Kyle D O'Connor,Kyra Shelton,Kristina Shvets,Nityasree Srialluri,Jia Wei Tan,Jeffrey M Testani,Celia P Corona-Villalobos,Yu Yamamoto,Chirag R Parikh,F Perry Wilson,
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Abstract

Importance Acute kidney injury (AKI) is a common complication during hospitalization and is associated with adverse outcomes. Objective To evaluate whether diagnostic and therapeutic recommendations sent by a kidney action team through the electronic health record improve outcomes among patients hospitalized with AKI compared with usual care. Design, Setting, and Participants Randomized clinical trial conducted at 7 hospitals in 2 health systems: in New Haven, Bridgeport, New London, and Waterbury, Connecticut, and Westerly, Rhode Island; and in Baltimore, Maryland. Hospitalized patients with AKI were randomized between October 29, 2021, and February 8, 2024. Final follow-up occurred February 22, 2024. Intervention An alert about AKI was sent to the kidney action team, consisting of a study physician and study pharmacist, which sent personalized recommendations through the electronic health record in 5 major categories (diagnostic testing, volume, potassium, acid base, and medications) within 1 hour of AKI detection. The note was immediately visible to anyone with access to the electronic health record. Randomization to the intervention or usual care occurred after the recommendations were generated, but the note was only delivered to clinicians of patients randomized to the intervention group. Main Outcomes and Measures The primary outcome was a composite outcome consisting of AKI progression to a higher stage of AKI, dialysis, or mortality occurring while the patient remained hospitalized and within 14 days from randomization. Results Of the 4003 patients randomized (median age, 72 years [IQR, 61-81 years), 1874 (47%) were female and 931 (23%) were Black patients. The kidney action team made 14 539 recommendations, with a median of 3 (IQR, 2-5) per patient. The primary outcome occurred in 19.8% of the intervention group and in 18.4% in the usual care group (difference, 1.4%, 95% CI, -1.1% to 3.8,% P = .28). Of 6 secondary outcomes, only 1 secondary outcome, rates of recommendation implementation, significantly differed between the 2 groups: 2459 of 7270 recommendations (33.8%) were implemented in the intervention group and 1766 of 7269 undelivered recommendations (24.3%) were implemented in the usual care group within 24 hours (difference, 9.5%; 95% CI, 8.1% to 11.0%). Conclusions and Relevance Among patients hospitalized with AKI, recommendations from a kidney action team did not significantly reduce the composite outcome of worsening AKI stage, dialysis, or mortality, despite a higher rate of recommendation implementation in the intervention group than in the usual care group. Trial Registration ClinicalTrials.gov Identifier: NCT04040296.
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针对急性肾损伤住院患者的早期个性化建议:随机临床试验
重要性急性肾损伤(AKI)是住院期间常见的并发症,与不良预后有关。目的评估与常规护理相比,肾脏行动小组通过电子健康记录发送的诊断和治疗建议是否能改善急性肾损伤住院患者的预后。设计、设置和参与者随机临床试验在两个医疗系统的 7 家医院进行:康涅狄格州纽黑文、布里奇波特、新伦敦、沃特伯里和罗德岛韦斯特利;马里兰州巴尔的摩。住院的 AKI 患者在 2021 年 10 月 29 日至 2024 年 2 月 8 日期间随机接受治疗。由一名研究医生和一名研究药剂师组成的肾脏行动小组收到 AKI 警报后,会在发现 AKI 的 1 小时内通过电子健康记录发送 5 大类个性化建议(诊断检测、血容量、血钾、酸碱度和药物)。任何可以访问电子病历的人都可以立即看到该记录。主要结果和测量指标主要结果是综合结果,包括 AKI 进展到更高阶段的 AKI、透析或死亡,发生在患者住院期间和随机分组后 14 天内。结果在 4003 名随机分组的患者中(中位年龄 72 岁 [IQR,61-81 岁]),1874 名(47%)为女性,931 名(23%)为黑人患者。肾脏行动小组提出了 14 539 项建议,每名患者的建议中位数为 3 项(IQR,2-5 项)。19.8%的干预组和18.4%的常规护理组出现了主要结果(差异为1.4%,95% CI,-1.1%至3.8%,P = .28)。在 6 项次要结果中,只有 1 项次要结果(建议执行率)在两组之间存在显著差异:干预组在 7270 项建议中执行了 2459 项(33.8%),而常规护理组在 7269 项未交付建议中执行了 1766 项(24.3%)(差异,9.5%;95% CI,8.1% 至 11.0%)。结论和相关性在住院的 AKI 患者中,尽管干预组的建议实施率高于常规护理组,但肾脏行动小组的建议并未显著降低 AKI 阶段恶化、透析或死亡率的综合结果:NCT04040296。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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