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

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.

Graphical abstract

Figure 1

Automated Surveillance Reporting dashboard for the IMPROVE AKI trial. (Top left) Observed over expected monthly rates of AKI; (top right) observed over expected benchmarking against for site and the site's Veterans Integrated Services Networks (VISN), region, and national AKI rates; (bottom left) risk-adjusted sequential probability ratio testing (RA-SPRT); (bottom right) patient process and outcome measures.

Figure 2

Consort diagram for IMPROVE AKI trial. Of 76 Veterans Affairs (VA) sites, 20 were randomized to one of four interventions.

Figure 3

Multilevel logistic models for AKI with site-level random effects for all cardiac catheterization patients and those patients with CKD. The following patient characteristics were included for adjustment: age, race, tobacco use, anemia, heart failure, CKD, diabetes, hypertension, prior percutaneous coronary intervention, and site baseline performance. In all patients, the Collaborative versus Assistance (with or without Surveillance), Surveillance versus None (for Collaborative or Assistance), and the specific Collaborative+Surveillance intervention cluster compared with Assistance alone showed statistically significant reductions in AKI. In the latter, the adjusted and unadjusted odds ratios were 0.54 [0.40–0.74] and 0.54 [0.40–0.72], respectively. Surveillance, Automated Surveillance Reporting; Assistance, Technical Assistance; Collaborative, Virtual Learning Collaborative.