A population-based, regression discontinuity analysis examined the effects of nationwide alerting for acute kidney injury on health care and patient outcomes.

Abstract

Previous randomized trials and real-world observational studies of electronic alerts for acute kidney injury (AKI) have yielded conflicting results. The applicability of trial findings to routine clinical practice is also contested. Despite this, AKI e-alerts remain widely implemented. Here, we used Regression Discontinuity Design (RDD) to evaluate the real-world causal effect of the nationwide AKI e-alert initiative in Wales. The study encompassed hospital and community-based systems serving 3.1 million adults (aged 18 years and older) residing in Wales, 2016-2020, following implementation of AKI e-alerts across all Welsh health boards, seven using passive alerts and one using interruptive alerts. We assessed outcomes across the e-alert threshold, including mortality, hospital admission/readmission, AKI severity and recovery, documentation of AKI, prescribing, and follow-up monitoring of proteinuria and blood pressure. Among 861,494 hospital and 354,505 community patient encounters, AKI alerts were triggered in 5.8% and 2.0% of cases respectively (mean age 64 years, 54% female). In both settings, AKI alerts led to no significant changes in mortality [complier average treatment effect +1.31% (95% Confidence Interval -3.07, 4.74); +2.07% (-3.44, 6.65)] or admissions/readmissions [+0.13% (-3.82, 4.21); +4.07% (-1.84, 8.27)]. AKI coding was infrequent across both settings. Alerts modestly increased hospital coding [+5.88% (2.22, 7.58)] but had minimal impact on primary care coding post discharge [+0.72% (-0.67, 1.30)] and led to only small improvements in proteinuria and blood pressure monitoring. Findings were consistent across passive and interruptive alert types, clinical settings and subgroups. We found no causal evidence that AKI e-alerts (specifically implemented at a 50% creatinine rise threshold) improved or worsened clinical outcomes in this nationwide real-world evaluation. Consistently poor outcomes, limited documentation and follow-up care, even in the presence of e-alerts, underscore the need for an improved clinical response to AKI.