Team-Based Coaching Intervention to Improve Contrast-Associated Acute Kidney Injury: A Cluster-Randomized Trial.

Jesse W Currier, Michael E Matheny, A James O'Malley, Kelly A Aschbrenner, Stephen W Waldo, Mary E Plomondon, Mladen I Vidovich, Ajay Agarwal, Thomas J Helton, Calvin Leung, Saket Girotra, S Ahmed Athar, Jeremiah R Brown, Hani Jneid, Freneka Minter, Kevin C Cox, Chad Dorn, Dax M Westerman, Lisa Zubkoff, Elizabeth Carpenter-Song, Sharon Davis, Meagan E Stabler, Richard Solomon

Journal: Clinical journal of the American Society of Nephrology : CJASN 2023;18(3):315-326

PMID: 36787125

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Abstract

BACKGROUND

Up to 14% of patients in the United States undergoing cardiac catheterization each year experience AKI. Consistent use of risk minimization preventive strategies may improve outcomes. We hypothesized that team-based coaching in a Virtual Learning Collaborative (Collaborative) would reduce postprocedural AKI compared with Technical Assistance (Assistance), both with and without Automated Surveillance Reporting (Surveillance).

METHODS

The IMPROVE AKI trial was a 2×2 factorial cluster-randomized trial across 20 Veterans Affairs medical centers (VAMCs). Participating VAMCs received Assistance, Assistance with Surveillance, Collaborative, or Collaborative with Surveillance for 18 months to implement AKI prevention strategies. The Assistance and Collaborative approaches promoted hydration and limited NPO and contrast dye dosing. We fit logistic regression models for AKI with site-level random effects accounting for the clustering of patients within medical centers with a prespecified interest in exploring differences across the four intervention arms.

RESULTS

Among VAMCs' 4517 patients, 510 experienced AKI (235 AKI events among 1314 patients with preexisting CKD). AKI events in each intervention cluster were 110 (13%) in Assistance, 122 (11%) in Assistance with Surveillance, 190 (13%) in Collaborative, and 88 (8%) in Collaborative with Surveillance. Compared with sites receiving Assistance alone, case-mix-adjusted differences in AKI event proportions were -3% (95% confidence interval [CI], -4 to -3) for Assistance with Surveillance, -3% (95% CI, -3 to -2) for Collaborative, and -5% (95% CI, -6 to -5) for Collaborative with Surveillance. The Collaborative with Surveillance intervention cluster had a substantial 46% reduction in AKI compared with Assistance alone (adjusted odds ratio=0.54; 0.40-0.74).

CONCLUSIONS

This implementation trial estimates that the combination of Collaborative with Surveillance reduced the odds of AKI by 46% at VAMCs and is suggestive of a reduction among patients with CKD.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

IMPROVE AKI Cluster-Randomized Trial (IMPROVE-AKI), NCT03556293.

Address: Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.; Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.; University of Vermont Larner College of Medicine, Burlington, Vermont.; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.; Department of Psychiatry and Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.; Department of Medicine, University of Alabama at Birmingham and VA Birmingham Health Care, Birmingham, Alabama.; Section of Cardiology, Baylor College of Medicine, Houston, Texas.; Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.; Division of Cardiology, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California.; Section of Cardiology, Loma Linda VA Medical Center, Loma Linda, California.; Department of Medicine, Division of Cardiology, Loma Linda University School of Medicine, Loma Linda, California.; Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.; Orlando VA Medical Center, Orlando, Florida.; East Tennessee State University, Johnson City, Tennessee.; Wright State University Dayton VA Medical Center, Dayton, Ohio.; Section of Cardiology, Jesse Brown VA Medical Center and Department of Medicine, University of Illinois at Chicago, Chicago, Illinois.; CART Program, VHA Office of Quality and Safety, Washington, DC.; Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado.; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado.; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.; Geriatric Research Education and Clinical Care Center, Tennessee Valley Healthcare System VA, Nashville, Tennessee.

DOI: 10.2215/CJN.0000000000000067

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MeSH Terms: Humans, United States, Mentoring, Contrast Media, United States Department of Veterans Affairs, Renal Insufficiency, Chronic, Acute Kidney Injury