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

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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr James reported receiving grants from Amgen Canada. Dr Spertus reported being a medical adviser to Health Outcomes Sciences, Terumo, which is the maker of ePRISM software; receiving grants from Abbott Vascular; receiving personal fees from Janssen, United Healthcare, Merck, Novartis, and Bayer; holding a patent and receiving royalties for the Seattle Angina Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Peripheral Artery Questionnaire; and being on the board of directors for Blue Cross Blue Shield of Kansas City. Dr Wilton reported receiving grants from Medtronic Canada, Abbott, and Boston Scientific and receiving personal fees from Arca Biopharma. Dr Klarenbach reported being the co-scientific director of the kidney health section of the Medicine Strategic Clinical Network within Alberta Health Services and receiving grants from the Real World Evidence Consortium (universities of Alberta and Calgary, Institute of Health Economics). No other disclosures were reported.

Figures

Figure 1.. Flow of Patients, Eligible Procedures, and Physicians in the Contrast RISK (Reducing Injury Sustained by Kidneys) Trial

Invasive cardiologists practicing at 3 cardiac catheterization laboratories in Alberta, Canada, were randomly assigned to 1 of 8 start dates (periods) between January 1, 2018, and September 1, 2019, and were included during the intervention period and the control (preintervention) period. Three physicians retired before receiving the intervention.

Figure 2.. Subgroup Analyses for the Effect of the Intervention on the Incidence of Acute Kidney Injury

Acute kidney injury was defined according to serum creatinine–based criteria from the Kidney Disease: Improving Global Outcomes acute kidney injury guidelines. The last serum creatinine measurement collected before the procedure was used to define the baseline value. Follow-up creatinine testing was performed between 48 hours and 96 hours after the procedures. The predicted risk of acute kidney injury was calculated using the National Cardiovascular Data Registry multivariable acute kidney injury risk prediction model. OR indicates odds ratio.