Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions. METHODS AND RESULTS: We conducted a prospective multicenter quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21 067 nonemergent patients undergoing percutaneous coronary interventions at 10 hospitals between 2007 and 2012. Six intervention hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as benchmark sites and were used to develop the intervention, and 2 hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital level, we calculated adjusted risk ratios for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (risk ratio, 0.79; 95% confidence interval: 0.67-0.93; P=0.005) for all patients and by 28% in patients with baseline estimated glomerular filtration rate <60 mL/min per 1.73 m(2) (risk ratio, 0.72; 95% confidence interval: 0.56-0.91; P=0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration. CONCLUSIONS: Simple cost-effective quality improvement interventions can prevent ≤1 in 5 CI-AKI events in patients with undergoing nonemergent percutaneous coronary interventions.

How do centres begin the process to prevent contrast-induced acute kidney injury: a report from a new regional collaborative.

OBJECTIVES: This study evaluates the variation in practice patterns associated with contrast-induced acute kidney injury (CI-AKI) and identifies clinical practices that have been associated with a reduction in CI-AKI. Background CI-AKI is recognised as a complication of invasive cardiovascular procedures and is associated with cardiovascular events, prolonged hospitalisation, end-stage renal disease, and all-cause mortality. Reducing the risk of CI-AKI is a patient safety objective set by the National Quality Forum. METHODS: This study prospectively collected quantitative and qualitative data from 10 centres, which participate in the Northern New England Cardiovascular Disease Study Group PCI Registry. Quantitative data were collected from the PCI Registry. Qualitative data were obtained through clinical team meetings to map care processes related to CI-AKI and focus groups to understand attitudes towards CI-AKI prophylaxis. Fixed and random effects modelling were conducted to test the differences across centres. RESULTS: Significant variation in rates of CI-AKI were found across 10 medical centres. Both fixed effects and mixed effects logistic regression demonstrated significant variability across centres, even after adjustment for baseline covariates (p<0.001 for both modelling approaches). Patterns were found in reported processes and clinical leadership that were attributable to centres with lower rates of CI-AKI. These included reducing nil by mouth (NPO) time to 4 h prior to case, and standardising volume administration protocols in combination with administering three to four high doses of N-acetylcysteine (1200 mg) for each patient. CONCLUSIONS: These data suggest that clinical leadership and institution-focused efforts to standardise preventive practices can help reduce the incidence of CI-AKI.

Recent changes in practice of elective percutaneous coronary intervention for stable angina.

BACKGROUND: The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to compare optimal medical therapy alone versus optimal medical therapy and percutaneous coronary intervention (PCI) for treatment of patients with stable coronary artery disease and showed equal efficacy for optimal medical therapy with or without PCI. The impact of results from the COURAGE trial on clinical practice is unknown. METHODS AND RESULTS: We analyzed 26 388 consecutive patients from the Northern New England Cardiovascular Disease PCI Registry who underwent PCI between January 2006 and June 2009. We identified a COURAGE-like patient group as patients who were undergoing (1) an elective procedure; (2) for an indication of stable angina; and (3) on the day of admission (ie, the date of admission was the same as the procedure date). All other PCI patients were placed in an "other indications" cohort. We compared temporal trends in overall volume in PCI for stable angina and for other indications, comparing quarterly time periods before and after release of COURAGE in March 2007. Over the study period, there was a statistically significant decrease in total PCI volume from 2064 in Quarter 1 2006 (before COURAGE) to 1708 in Quarter 3 2007 (after COURAGE) (P<0.01). These trends were sustained through June 2009, with an approximate 16% peak relative reduction in all PCI compared with before COURAGE. As a percentage of all PCI, stable angina reached a high of 20.9% before COURAGE and began to decrease immediately after publication of COURAGE in Quarter 2 2007 to 16.1% (P<0.01). Among patients undergoing PCI for stable angina, there was a significant 26% peak decrease in post-COURAGE PCI volumes compared with pre-COURAGE Quarter 1 2006 (P trend, 0.01), which was maintained through the end of the study period. CONCLUSIONS: Publication of results from the COURAGE trial was temporally associated with a significant and sustained decline in the use of PCI to treat patients with stable angina. The long-term impact of this change in practice on patient outcomes remains to be determined.