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Cited by 59Acute Kidney Injury ResearchCoronary Interventions and DiagnosticsElectronic Health Records Systems

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

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James, Matthew T., Har, Bryan J., Tyrrell, Benjamin D., Faris, Peter D., Tan, Zhi, Spertus, John A., Wilton, Stephen B., Ghali, William A. +5 more·2022·JAMA
DOI 10.1001/jama.2022.13382PMC PMC9449791
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Abstract

Importance: Contrast-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. Objective: To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI. Design, Setting, and Participants: A 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. Interventions: During 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 Measures: The 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. Results: Of 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 Relevance: Among 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 Registration: ClinicalTrials.gov Identifier: NCT03453996

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  • Imperative AI-based CDS has been effective in some direct use cases.

    “Imperative AI-based CDS has been effective in some direct use cases, supporting this approach,80 but it runs the risk of automation bias.81,82”

    From Potential uses of AI for perioperative nursing handoffs: a qualitative study (2023) · cites this paper as [80]

    The Discussion (page unavailable) reports that a point-of-care clinical decision support intervention helped reduce acute kidney injury in patients undergoing coronary angiography or PCI. But it was combined with educational outreach and audit and feedback, and the authors say they cannot disentangle the components’ effects. The Methods describe risk prediction and automated targets, but do not establish that the system was AI-based or that decision support alone was effective. (LLM, conf=0.88)

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Authors
James, M. T., Har, B. J., Tyrrell, B. D., Faris, P. D., Tan, Z., Spertus, J. A., Wilton, S. B., Ghali, W. A., Knudtson, M. L., Sajobi, T. T., Pannu, N. I., Klarenbach, S. W., & Graham, M. M.
Affiliations
  • University of Calgary (CA)
  • University of Alberta (CA)
  • Alberta Health Services (CA)
  • Saint Luke's Hospital (US)
Corresponding author
James, Matthew T.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2022-09-06
Volume
328
Issue
9
Pages
839
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2022.13382
PMC
PMC9449791
OpenAlex
W4294771393
Cited by
59
References
43
Citations by year
2026: 8 · 2025: 22 · 2024: 7 · 2023: 17 · 2022: 5
FWCI
8.09
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Nephrology › Acute Kidney Injury Research
  • Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Keywords
acute kidney injury, contrast-induced nephropathy, coronary angiography, percutaneous coronary intervention, clinical decision support, audit and feedback, contrast volume, intravenous fluid management, catheterization laboratory, AKI prevention, Alberta, Canada, United States
MeSH terms
Aged, Aged, 80 and over, Contrast Media, Feedback, Female, Humans, Male, Medical Audit, Middle Aged, Coronary Angiography, Risk Assessment, Decision Support Systems, Clinical, Acute Kidney Injury, Percutaneous Coronary Intervention

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