Neal Yuan, Justin Zhang, Rakan Khaki, Derek Leong, Chandrashekhar Bhoopalam, Steven W Tabak, Yaron Elad, Joshua M Pevnick, Susan Cheng, Joseph E Ebinger
{"title":"实施基于电子健康记录的安全对比剂限制,预防经皮冠状动脉介入术后对比剂相关急性肾损伤。","authors":"Neal Yuan, Justin Zhang, Rakan Khaki, Derek Leong, Chandrashekhar Bhoopalam, Steven W Tabak, Yaron Elad, Joshua M Pevnick, Susan Cheng, Joseph E Ebinger","doi":"10.1161/CIRCOUTCOMES.122.009235","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention is associated with increased mortality. We assessed the effectiveness of an electronic health records safe contrast limit tool in predicting CA-AKI risk and reducing contrast use and CA-AKI.</p><p><strong>Methods: </strong>We created an alert displaying the safe contrast limit to cardiac catheterization laboratory staff prior to percutaneous coronary intervention. The alert used risk factors automatically extracted from the electronic health records. We included procedures from June 1, 2020 to October 1, 2021; the intervention went live February 10, 2021. Using difference-in-differences analysis, we evaluated changes in contrast volume and CA-AKI rates after contrast limit tool implementation compared to control hospitals. Cardiologists were surveyed prior to and 9 months after alert implementation on beliefs, practice patterns, and safe contrast estimates for example patients.</p><p><strong>Results: </strong>At the one intervention site, there were 508 percutaneous coronary interventions before and 531 after tool deployment. At 15 control sites, there were 3550 and 3979 percutaneous coronary interventions, respectively. The contrast limit predicted CA-AKI with an accuracy of 64.1%, negative predictive value of 93.3%, and positive predictive value of 18.7%. After implementation, in high/modifiable risk patients (defined as having a calculated contrast limit <500ml) there was a small but significant -4.60 mL/month (95% CI, -8.24 to -1.00) change in average contrast use but no change in CA-AKI rates (odds ratio, 0.96 [95% CI, 0.84-1.10]). Low-risk patients had no change in contrast use (-0.50 mL/month [95% CI, -7.49 to 6.49]) or CA-AKI (odds ratio, 1.24 [95% CI, 0.79-1.93]). In assessing CA-AKI risk, clinicians heavily weighted age and diabetes but often did not consider anemia, cardiogenic shock, and heart failure.</p><p><strong>Conclusions: </strong>Clinicians often used a simplified assessment of CA-AKI risk that did not include important risk factors, leading to risk estimations inconsistent with established models. Despite clinician skepticism, an electronic health records-based contrast limit tool more accurately predicted CA-AKI risk and was associated with a small decrease in contrast use during percutaneous coronary intervention but no change in CA-AKI rates.</p>","PeriodicalId":10301,"journal":{"name":"Circulation. Cardiovascular Quality and Outcomes","volume":"16 1","pages":"e009235"},"PeriodicalIF":6.9000,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9858238/pdf/","citationCount":"0","resultStr":"{\"title\":\"Implementation of an Electronic Health Records-Based Safe Contrast Limit for Preventing Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention.\",\"authors\":\"Neal Yuan, Justin Zhang, Rakan Khaki, Derek Leong, Chandrashekhar Bhoopalam, Steven W Tabak, Yaron Elad, Joshua M Pevnick, Susan Cheng, Joseph E Ebinger\",\"doi\":\"10.1161/CIRCOUTCOMES.122.009235\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention is associated with increased mortality. We assessed the effectiveness of an electronic health records safe contrast limit tool in predicting CA-AKI risk and reducing contrast use and CA-AKI.</p><p><strong>Methods: </strong>We created an alert displaying the safe contrast limit to cardiac catheterization laboratory staff prior to percutaneous coronary intervention. The alert used risk factors automatically extracted from the electronic health records. We included procedures from June 1, 2020 to October 1, 2021; the intervention went live February 10, 2021. Using difference-in-differences analysis, we evaluated changes in contrast volume and CA-AKI rates after contrast limit tool implementation compared to control hospitals. Cardiologists were surveyed prior to and 9 months after alert implementation on beliefs, practice patterns, and safe contrast estimates for example patients.</p><p><strong>Results: </strong>At the one intervention site, there were 508 percutaneous coronary interventions before and 531 after tool deployment. At 15 control sites, there were 3550 and 3979 percutaneous coronary interventions, respectively. The contrast limit predicted CA-AKI with an accuracy of 64.1%, negative predictive value of 93.3%, and positive predictive value of 18.7%. After implementation, in high/modifiable risk patients (defined as having a calculated contrast limit <500ml) there was a small but significant -4.60 mL/month (95% CI, -8.24 to -1.00) change in average contrast use but no change in CA-AKI rates (odds ratio, 0.96 [95% CI, 0.84-1.10]). Low-risk patients had no change in contrast use (-0.50 mL/month [95% CI, -7.49 to 6.49]) or CA-AKI (odds ratio, 1.24 [95% CI, 0.79-1.93]). In assessing CA-AKI risk, clinicians heavily weighted age and diabetes but often did not consider anemia, cardiogenic shock, and heart failure.</p><p><strong>Conclusions: </strong>Clinicians often used a simplified assessment of CA-AKI risk that did not include important risk factors, leading to risk estimations inconsistent with established models. Despite clinician skepticism, an electronic health records-based contrast limit tool more accurately predicted CA-AKI risk and was associated with a small decrease in contrast use during percutaneous coronary intervention but no change in CA-AKI rates.</p>\",\"PeriodicalId\":10301,\"journal\":{\"name\":\"Circulation. 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Implementation of an Electronic Health Records-Based Safe Contrast Limit for Preventing Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention.
Background: Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention is associated with increased mortality. We assessed the effectiveness of an electronic health records safe contrast limit tool in predicting CA-AKI risk and reducing contrast use and CA-AKI.
Methods: We created an alert displaying the safe contrast limit to cardiac catheterization laboratory staff prior to percutaneous coronary intervention. The alert used risk factors automatically extracted from the electronic health records. We included procedures from June 1, 2020 to October 1, 2021; the intervention went live February 10, 2021. Using difference-in-differences analysis, we evaluated changes in contrast volume and CA-AKI rates after contrast limit tool implementation compared to control hospitals. Cardiologists were surveyed prior to and 9 months after alert implementation on beliefs, practice patterns, and safe contrast estimates for example patients.
Results: At the one intervention site, there were 508 percutaneous coronary interventions before and 531 after tool deployment. At 15 control sites, there were 3550 and 3979 percutaneous coronary interventions, respectively. The contrast limit predicted CA-AKI with an accuracy of 64.1%, negative predictive value of 93.3%, and positive predictive value of 18.7%. After implementation, in high/modifiable risk patients (defined as having a calculated contrast limit <500ml) there was a small but significant -4.60 mL/month (95% CI, -8.24 to -1.00) change in average contrast use but no change in CA-AKI rates (odds ratio, 0.96 [95% CI, 0.84-1.10]). Low-risk patients had no change in contrast use (-0.50 mL/month [95% CI, -7.49 to 6.49]) or CA-AKI (odds ratio, 1.24 [95% CI, 0.79-1.93]). In assessing CA-AKI risk, clinicians heavily weighted age and diabetes but often did not consider anemia, cardiogenic shock, and heart failure.
Conclusions: Clinicians often used a simplified assessment of CA-AKI risk that did not include important risk factors, leading to risk estimations inconsistent with established models. Despite clinician skepticism, an electronic health records-based contrast limit tool more accurately predicted CA-AKI risk and was associated with a small decrease in contrast use during percutaneous coronary intervention but no change in CA-AKI rates.
期刊介绍:
Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal, publishes articles related to improving cardiovascular health and health care. Content includes original research, reviews, and case studies relevant to clinical decision-making and healthcare policy. The online-only journal is dedicated to furthering the mission of promoting safe, effective, efficient, equitable, timely, and patient-centered care. Through its articles and contributions, the journal equips you with the knowledge you need to improve clinical care and population health, and allows you to engage in scholarly activities of consequence to the health of the public. Circulation: Cardiovascular Quality and Outcomes considers the following types of articles: Original Research Articles, Data Reports, Methods Papers, Cardiovascular Perspectives, Care Innovations, Novel Statistical Methods, Policy Briefs, Data Visualizations, and Caregiver or Patient Viewpoints.