Clinical decision support reduces risk of AKI development with coronary procedures
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Patients undergoing coronary procedures who received care from a cardiologist using clinical decision support with audit and feedback were less likely to develop AKI compared with patients who received usual care, according to researchers.
“Between 4% and 10% of patients undergoing coronary angiography or percutaneous coronary intervention (PCI) experience AKI and the cost of attributable care has been estimated as high as $1.67 billion annually in the U.S.,” Matthew T. James, MD, PhD, from the department of medicine at Cumming School of Medicine at University of Calgary in Canada, and colleagues wrote. They added, “The large variation in practice patterns among physicians and AKI rates suggest that prevention of AKI in patients undergoing coronary angiography or PCI could be improved, and tailored strategies might guide clinicians toward identifying high-risk patients and incorporating tactics to support AKI prevention.”
In a stepped-wedge, cluster randomized clinical trial, researchers evaluated 34 invasive cardiologists at three cardiac catheterization laboratories in Alberta, Canada, between January 2018 and September 2019, as they performed non-emergency coronary angiography or PCI on 7,106 adults who were not undergoing dialysis and who had a predicted AKI risk greater than 5%.
Cardiologists provided usual care during the control period of the study, then they were randomly assigned to one of eight start groups for the intervention period. The intervention consisted of educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. AKI served as the primary outcome of the study, and patient follow-up ended in November 2020.
In the intervention group, 31 cardiologists conducted 4,327 procedures among 4,032 patients (patients’ mean age was 70.3 years; 1,384 were women), and the control group included 34 cardiologists who performed 3,493 procedures among 3,251 patients (patients’ mean age was 70.2 years; 1,151 were women).
The incidence of AKI was 7.2% during the intervention period and 8.6% during the control period.
With the intervention, researchers identified a reduction in which excessive contrast volumes were used from 51.7% to 38.1%, and a reduction in eligible patients in whom insufficient intravenous fluid was given from 75.1% to 60.8%.
Researchers found no group differences in major adverse cardiovascular or kidney events.
“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%,” James and colleagues wrote. “Whether this intervention would show efficacy outside this study setting requires further investigation.”
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