Effects of nationwide alerting for acute kidney injury on healthcare and patient outcomes: population based, regression discontinuity analysis

ObjectiveTo determine whether the implementation of electronic alerts for acute kidney injury improves care and outcomes in real-world clinical practice. DesignPopulation-based, regression discontinuity analysis SettingHospital and community-based systems across all 8 health boards in Wales, from 2016 to 2021 following implementation of AKI alerts. Participants3.1 million adults aged [≥]18 years resident and registered at GP practices in Wales between the years of 2016-2021, following implementation of AKI e-alerts across all 8 Wales health boards. ExposureElectronic alerts for acute kidney injury provided in either a passive (7 boards) or interruptive (1 board) manner to physicians through laboratory reporting systems. Main outcome measuresMortality, hospital admission or readmission, severity and recovery of AKI, coding of acute kidney injury, proteinuria and blood pressure measurements. ResultsAmong 861,494 and 354,505 eligible patient encounters, 5.8% and 2.0% AKI alerts were generated from hospital and community settings, respectively; mean age 64 years, 54% female. In both hospital and community settings, respectively, AKI alerts led to no significant differences in mortality [complier average treatment effect +1.31% (95% CI -3.07, 4.74); +2.07% (95% CI -3.44, 6.65)] or admissions/readmissions [+0.13% (95% CI -3.82, 4.21); +4.07% (95% CI -1.84, 8.27)]. There was a modest increase in hospital coding of AKI with alerts [+5.88% (95% CI 2.22, 7.58)], but no difference in primary care coding of AKI after discharge [+0.72% (95% CI -0.67, 1.30)]. Alerts exerted small increases on subsequent checks for proteinuria and of blood pressure. Findings were consistent for passive and interruptive alerts. There were no meaningful differences by rurality, deprivation, sex, history of surgery, diabetes, or vascular disease. ConclusionsThe nationwide implementation of AKI alerts in Wales produced small effects on documentation of AKI and some processes of care but exerted no effects on survival or hospital admissions in acute care or community settings. The consistently poor outcomes, and the deficiencies in documentation and care after AKI highlight the ongoing need for an improved clinical response. RegistrationA prespecified analysis protocol is available at Open Science Framework (OSF) repository (https://osf.io/f4wz9/?view_only=d20e49817bc74f1fa66afc7aa8dda0ab) SummaryO_ST_ABSWhat is knownC_ST_ABSPrevious randomised trials and real-world observational studies of electronic alerts for acute kidney injury (AKI) have produced mixed results. The applicability of previous trials for real-world clinical practice remains uncertain and contested. AKI e-alerts are still widely used. What we didWe applied Regression Discontinuity Design (RDD), a method gaining traction in clinical research. RDD can work like an ideal target trial to enable causal inference in real-world settings. RDD is particularly effective when clinical actions are triggered by a specific measurement threshold. This approach allowed us we to evaluate a nationwide AKI e-alert initiative across Wales. What we foundWe found no evidence that AKI e-alerts improved or worsened outcomes across any clinical setting, patient subgroup, or alert delivery method. Nonetheless, the consistently poor outcomes, and the deficiencies in documentation and care after AKI highlight the ongoing need for an improved clinical response.