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Singh JA, Cleveland JD. Acute kidney injury is associated with increased healthcare utilization, complications, and mortality after primary total knee arthroplasty. Ther Adv Musculoskelet Dis 2020; 12:1759720X20908723. [PMID: 32127927 PMCID: PMC7036495 DOI: 10.1177/1759720x20908723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/24/2020] [Indexed: 01/20/2023] Open
Abstract
Background: The objective of this study was to assess healthcare utilization and
complications associated with acute kidney injury (AKI) in patients
undergoing primary total knee arthroplasty (TKA). Methods: We used the 1998–2014 US National Inpatient Sample to assess whether AKI is
associated with healthcare utilization or in-hospital postoperative
complications post-TKA using multivariable-adjusted logistic regression
analyses. We calculated odds ratios (ORs) and a 95% confidence intervals
(CIs). Sensitivity analyses additionally adjusted for hospital
characteristics (location/teaching status, bed size, and region). Results: Of the 8,127,282 people who underwent primary TKA from 1998 to 2014, 104,366
(1.3%) had a diagnosis of AKI. People with AKI had longer unadjusted mean
hospital stay, 6.1 versus 3.5 days, higher mean hospital
charges, US$71,385 versus US$42,067, and higher rates of
all in-hospital postoperative complications, including mortality. Adjusted
for age, sex, race, underlying diagnosis, medical comorbidity, income, and
insurance payer, AKI was associated with a significantly higher OR (95% CI)
of total hospital charges above the median, 2.76 (2.68, 2.85); length of
hospital stay > 3 days, 2.21 (2.14, 2.28); and discharge to a
rehabilitation facility, 4.68 (4.54, 4.83). AKI was associated with
significantly higher OR (95% CI) of in-hospital complications, including
infection, 2.60 (1.97, 3.43); transfusion, 2.94 (2.85, 3.03); revision, 2.13
(1.72, 2.64); and mortality, 19.75 (17.39, 22.42). Sensitivity analyses
replicated the main study findings, without any attenuation of ORs. Conclusions: AKI is associated with a significantly higher risk of increased healthcare
utilization, complications, and mortality after primary TKA. Future studies
should assess significant factors associated and interventions that can
prevent AKI.
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Affiliation(s)
- Jasvinder A Singh
- University of Alabama, Faculty Office Tower 805B, 510 20 Street S, Birmingham, AL 35294, USA
| | - John D Cleveland
- Department of Medicine at the School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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2
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Evaluation of a digitally-enabled care pathway for acute kidney injury management in hospital emergency admissions. NPJ Digit Med 2019; 2:67. [PMID: 31396561 PMCID: PMC6669220 DOI: 10.1038/s41746-019-0100-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/27/2019] [Indexed: 02/03/2023] Open
Abstract
We developed a digitally enabled care pathway for acute kidney injury (AKI) management incorporating a mobile detection application, specialist clinical response team and care protocol. Clinical outcome data were collected from adults with AKI on emergency admission before (May 2016 to January 2017) and after (May to September 2017) deployment at the intervention site and another not receiving the intervention. Changes in primary outcome (serum creatinine recovery to ≤120% baseline at hospital discharge) and secondary outcomes (30-day survival, renal replacement therapy, renal or intensive care unit (ICU) admission, worsening AKI stage and length of stay) were measured using interrupted time-series regression. Processes of care data (time to AKI recognition, time to treatment) were extracted from casenotes, and compared over two 9-month periods before and after implementation (January to September 2016 and 2017, respectively) using pre–post analysis. There was no step change in renal recovery or any of the secondary outcomes. Trends for creatinine recovery rates (estimated odds ratio (OR) = 1.04, 95% confidence interval (95% CI): 1.00–1.08, p = 0.038) and renal or ICU admission (OR = 0.95, 95% CI: 0.90–1.00, p = 0.044) improved significantly at the intervention site. However, difference-in-difference analyses between sites for creatinine recovery (estimated OR = 0.95, 95% CI: 0.90–1.00, p = 0.053) and renal or ICU admission (OR = 1.06, 95% CI: 0.98–1.16, p = 0.140) were not significant. Among process measures, time to AKI recognition and treatment of nephrotoxicity improved significantly (p < 0.001 and 0.047 respectively).
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Connell A, Black G, Montgomery H, Martin P, Nightingale C, King D, Karthikesalingam A, Hughes C, Back T, Ayoub K, Suleyman M, Jones G, Cross J, Stanley S, Emerson M, Merrick C, Rees G, Laing C, Raine R. Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals. J Med Internet Res 2019; 21:e13143. [PMID: 31368443 PMCID: PMC6693304 DOI: 10.2196/13143] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/29/2019] [Accepted: 03/24/2019] [Indexed: 01/16/2023] Open
Abstract
Background One reason for the introduction of digital technologies into health care has been to try to improve safety and patient outcomes by providing real-time access to patient data and enhancing communication among health care professionals. However, the adoption of such technologies into clinical pathways has been less examined, and the impacts on users and the broader health system are poorly understood. We sought to address this by studying the impacts of introducing a digitally enabled care pathway for patients with acute kidney injury (AKI) at a tertiary referral hospital in the United Kingdom. A dedicated clinical response team—comprising existing nephrology and patient-at-risk and resuscitation teams—received AKI alerts in real time via Streams, a mobile app. Here, we present a qualitative evaluation of the experiences of users and other health care professionals whose work was affected by the implementation of the care pathway. Objective The aim of this study was to qualitatively evaluate the impact of mobile results viewing and automated alerting as part of a digitally enabled care pathway on the working practices of users and their interprofessional relationships. Methods A total of 19 semistructured interviews were conducted with members of the AKI response team and clinicians with whom they interacted across the hospital. Interviews were analyzed using inductive and deductive thematic analysis. Results The digitally enabled care pathway improved access to patient information and expedited early specialist care. Opportunities were identified for more constructive planning of end-of-life care due to the earlier detection and alerting of deterioration. However, the shift toward early detection also highlighted resource constraints and some clinical uncertainty about the value of intervening at this stage. The real-time availability of information altered communication flows within and between clinical teams and across professional groups. Conclusions Digital technologies allow early detection of adverse events and of patients at risk of deterioration, with the potential to improve outcomes. They may also increase the efficiency of health care professionals’ working practices. However, when planning and implementing digital information innovations in health care, the following factors should also be considered: the provision of clinical training to effectively manage early detection, resources to cope with additional workload, support to manage perceived information overload, and the optimization of algorithms to minimize unnecessary alerts.
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Affiliation(s)
- Alistair Connell
- Centre for Human Health and Performance, University College London, London, United Kingdom.,DeepMind Health, London, United Kingdom
| | - Georgia Black
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Hugh Montgomery
- Centre for Human Health and Performance, University College London, London, United Kingdom
| | - Peter Martin
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Claire Nightingale
- Department of Applied Health Research, University College London, London, United Kingdom.,Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | | | | | | | | | | | | | - Gareth Jones
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jennifer Cross
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Sarah Stanley
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Mary Emerson
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Charles Merrick
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Geraint Rees
- Faculty of Life Sciences, University College London, London, United Kingdom
| | | | - Rosalind Raine
- Department of Applied Health Research, University College London, London, United Kingdom
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4
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Connell A, Raine R, Martin P, Barbosa EC, Morris S, Nightingale C, Sadeghi-Alavijeh O, King D, Karthikesalingam A, Hughes C, Back T, Ayoub K, Suleyman M, Jones G, Cross J, Stanley S, Emerson M, Merrick C, Rees G, Montgomery H, Laing C. Implementation of a Digitally Enabled Care Pathway (Part 1): Impact on Clinical Outcomes and Associated Health Care Costs. J Med Internet Res 2019; 21:e13147. [PMID: 31368447 PMCID: PMC6693300 DOI: 10.2196/13147] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 01/22/2023] Open
Abstract
Background The development of acute kidney injury (AKI) in hospitalized patients is associated with adverse outcomes and increased health care costs. Simple automated e-alerts indicating its presence do not appear to improve outcomes, perhaps because of a lack of explicitly defined integration with a clinical response. Objective We sought to test this hypothesis by evaluating the impact of a digitally enabled intervention on clinical outcomes and health care costs associated with AKI in hospitalized patients. Methods We developed a care pathway comprising automated AKI detection, mobile clinician notification, in-app triage, and a protocolized specialist clinical response. We evaluated its impact by comparing data from pre- and postimplementation phases (May 2016 to January 2017 and May to September 2017, respectively) at the intervention site and another site not receiving the intervention. Clinical outcomes were analyzed using segmented regression analysis. The primary outcome was recovery of renal function to ≤120% of baseline by hospital discharge. Secondary clinical outcomes were mortality within 30 days of alert, progression of AKI stage, transfer to renal/intensive care units, hospital re-admission within 30 days of discharge, dependence on renal replacement therapy 30 days after discharge, and hospital-wide cardiac arrest rate. Time taken for specialist review of AKI alerts was measured. Impact on health care costs as defined by Patient-Level Information and Costing System data was evaluated using difference-in-differences (DID) analysis. Results The median time to AKI alert review by a specialist was 14.0 min (interquartile range 1.0-60.0 min). There was no impact on the primary outcome (estimated odds ratio [OR] 1.00, 95% CI 0.58-1.71; P=.99). Although the hospital-wide cardiac arrest rate fell significantly at the intervention site (OR 0.55, 95% CI 0.38-0.76; P<.001), DID analysis with the comparator site was not significant (OR 1.13, 95% CI 0.63-1.99; P=.69). There was no impact on other secondary clinical outcomes. Mean health care costs per patient were reduced by £2123 (95% CI −£4024 to −£222; P=.03), not including costs of providing the technology. Conclusions The digitally enabled clinical intervention to detect and treat AKI in hospitalized patients reduced health care costs and possibly reduced cardiac arrest rates. Its impact on other clinical outcomes and identification of the active components of the pathway requires clarification through evaluation across multiple sites.
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Affiliation(s)
- Alistair Connell
- Centre for Human Health and Performance, University College London, London, United Kingdom.,DeepMind Health, London, United Kingdom
| | - Rosalind Raine
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Peter Martin
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Estela Capelas Barbosa
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Claire Nightingale
- Department of Applied Health Research, University College London, London, United Kingdom.,Population Health Research Institute, St George's, University of London, London, United Kingdom
| | | | | | | | | | | | | | | | - Gareth Jones
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jennifer Cross
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Sarah Stanley
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Mary Emerson
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Charles Merrick
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Geraint Rees
- Faculty of Life Sciences, University College London, London, United Kingdom
| | - Hugh Montgomery
- Centre for Human Health and Performance, University College London, London, United Kingdom
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Kothari T, Jensen K, Mallon D, Brogan G, Crawford J. Impact of Daily Electronic Laboratory Alerting on Early Detection and Clinical Documentation of Acute Kidney Injury in Hospital Settings. Acad Pathol 2018; 5:2374289518816502. [PMID: 30547082 PMCID: PMC6287301 DOI: 10.1177/2374289518816502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 02/02/2023] Open
Abstract
Acute kidney injury, especially early-stage disease, is a common hospital comorbidity requiring timely recognition and treatment. We investigated the effect of daily laboratory alerting of patients at risk for acute kidney injury as measured by documented International Classification of Diseases diagnoses. A quasi-experimental study was conducted at 8 New York hospitals between January 1, 2014, and June 30, 2017. Education of clinical documentation improvement specialists, physicians, and nurses was conducted from July 1, 2014, to December 31, 2014, prior to initiating daily hospital-wide laboratory acute kidney injury alerting on January 1, 2015. Incidence based on documented International Classification of Diseases diagnosis of acute kidney injury and acute tubular necrosis during the intervention periods (3 periods of 6 months each: January 1 to June 30 of 2015, 2016, and 2017) were compared to one preintervention period (January 1, 2014, to June 30, 2014). The sample consisted of 269 607 adult hospital discharges, among which there were 39 071 episodes based on laboratory estimates and 27 660 episodes of documented International Classification of Diseases diagnoses of acute kidney injury or acute tubular necrosis. Documented incidence improved significantly from the 2014 preintervention period (5.70%; 95% confidence interval: 5.52%-5.88%) to intervention periods in 2015 (9.89%; 95% confidence interval, 9.66%-10.12%; risk ratio = 1.73, P < .001), 2016 (12.76%; 95% confidence interval, 12.51%-13.01%; risk ratio = 2.24, P < .001), and 2017 (12.49%; 95% confidence interval, 12.24%-12.74%; risk ratio = 2.19, P < .001). A multifactorial intervention comprising daily laboratory alerting and education of physicians, nurses, and clinical documentation improvement specialists led to increased recognition and clinical documentation of acute kidney injury.
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Affiliation(s)
- Tarush Kothari
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kendal Jensen
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Debbie Mallon
- Clinical Documentation Improvement, Northwell Health, Lake Success, NY, USA
| | - Gerard Brogan
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - James Crawford
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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