Electronic health record alerts for acute kidney injury: multicenter, randomized clinical trial

Abstract

Objective: 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.

Trial registration: ClinicalTrials.gov NCT02753751.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform 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.

© 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.

Figures

Fig 1

Screenshot of the acute kidney injury (AKI) alert. Creatinine 1 mg/dL=88.42 μmol/L.

Fig 2

Primary and secondary outcome events, stratified by hospital type. Error bars are 95% confidence intervals of the observed proportion of events. AKI=acute kidney injury

Fig 3

Prespecified subgroup analyses show similar alert effect across a diverse array of patient characteristics. Diamonds reflect relative risk, with bars showing 95% confidence interval. Creatinine 1 mg/dL=88.42 μmol/L. ICU=intensive care unit