Original Investigation 

September 6, 2022

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

Matthew T. James, Bryan J. Har, Benjamin D. Tyrrell, et al

JAMA. 2022;328(9):839-849. doi:10.1001/jama.2022.13382

Key Points

Question  What is the effectiveness of clinical decision support, accompanied by audit and feedback to physicians, for prevention of acute kidney injury in patients undergoing coronary angiography, percutaneous coronary intervention, or both?

Findings  In this stepped-wedge, cluster randomized clinical trial conducted in Alberta, Canada, that included 34 cardiologists who performed 7820 procedures, the incidence of acute kidney injury during the intervention period compared with the control period was 7.2% vs 8.6%, a difference that was statistically significant.

Meaning  This multifaceted intervention led to a lower risk of acute kidney injury in patients undergoing coronary angiography, percutaneous coronary intervention, or both; however, whether this intervention would be effective in other settings requires further investigation.

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