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,
{"title":"Early, Individualized Recommendations for Hospitalized Patients With Acute Kidney Injury: A Randomized Clinical Trial.","authors":"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,","doi":"10.1001/jama.2024.22718","DOIUrl":null,"url":null,"abstract":"Importance\r\nAcute kidney injury (AKI) is a common complication during hospitalization and is associated with adverse outcomes.\r\n\r\nObjective\r\nTo 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.\r\n\r\nDesign, Setting, and Participants\r\nRandomized 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.\r\n\r\nIntervention\r\nAn 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.\r\n\r\nMain Outcomes and Measures\r\nThe 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.\r\n\r\nResults\r\nOf 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%).\r\n\r\nConclusions and Relevance\r\nAmong 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.\r\n\r\nTrial Registration\r\nClinicalTrials.gov Identifier: NCT04040296.","PeriodicalId":518009,"journal":{"name":"JAMA","volume":"60 1","pages":""},"PeriodicalIF":0.0000,"publicationDate":"2024-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"JAMA","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1001/jama.2024.22718","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
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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.