(MEnD-AKI) Multicenter Implementation of an Electronic Decision Support System for Drug-associated AKI

摘要 美国的急性肾损伤(AKI)在过去的八年里增加了38%，其中药物是主要的 住院患者AKI的贡献者。药物相关AKI(D-AKI)导致严重后果 约40%的患者在住院期间死亡或依赖透析，70%的患者 最初的D-AKI事件后残留肾脏损害的证据。我们已经确定，许多患者 AKI的高危人群被发现较晚，并且经常继续接受肾毒性药物治疗，直到AKI成为 很严重。因此，我们设计了一项建议，以满足早期、适当地处理肾毒素的需要。 通过研究先进的临床决策支持系统(CDSS)对高危患者的影响 医生和住院医生的目标是减少住院成年人的D-AKI。具体地说，我们的目标是1)优化 临床决策支持系统生成的D-AKI风险警报的临床性能；2)测试 先进的临床决策支持系统与药剂师主导的干预相结合，改善了短期和长期 D-AKI患者的长期结局；以及3)决定医生对药剂师 我们干预的绩效、医生接受度和成本效益。 2012年，肾脏疾病改善全球预后组织(KDIGO)发表了首个全面的AKI临床报告 实践指南。建议包括使用定义和分期AKI的标准标准以及 对于所有AKI患者或有发生AKI风险的患者，应考虑采取一系列基于阶段的管理步骤。 然而，临床医生在采纳这些建议和一些群体(最明显的是美国)方面进展缓慢 KDOQI专家小组)在总体上支持该指南的同时，呼吁进行更多的研究来测试 建议。我们的建议通过测试一个独特的临床决定是否直接解决了这一问题 识别高危患者的支持系统，以及针对 主治医生可以解决D-AKI和其他形式的AKI的药物剂量问题，以改善患者的护理。因此，我们的 中心目标是检查药剂师领导的干预对早期发现和管理的影响。 AKI、AKI的进展和短期恢复以及与AKI相关的各种结果。

Abstract Acute Kidney Injury (AKI) in the US has increased by 38% over the last eight years, with drugs as a major contributor to AKI in hospitalized patients. Drug-associated AKI (D-AKI) results in severe consequences with approximately 40% of patients experiencing in-hospital death or dialysis dependence and 70% having evidence of residual kidney damage following the initial D-AKI event. We have determined that many patients at high risk for AKI are identified late and often continue to receive nephrotoxic drugs until AKI becomes severe. Thus, we designed a proposal to address the need for early, appropriate management of nephrotoxins in high-risk patients by studying the effect of an advanced clinical decision support system (CDSS) for primary physicians and hospitalists aimed at reducing D-AKI in hospitalized adults. Specifically, we aim to 1) optimize the clinical performance of D-AKI risk-alerts generated by a clinical decision support system; 2) test whether an advanced clinical decision support system coupled with a pharmacist-led intervention improves short and long- term outcomes for patients with D-AKI; and 3) determine physician perception of the pharmacists’ performance, physician acceptance and cost-effectiveness of our intervention. In 2012 Kidney Disease Improving Global Outcomes (KDIGO) published the first comprehensive AKI clinical practice guideline. Recommendations include the use of standard criteria for defining and staging AKI and a series of stage-based management steps to be considered for all patients with AKI or at risk for developing it. However, clinicians have been slow to adopt these recommendations and some groups (most notably the US KDOQI expert panel), while endorsing the guideline overall, have called for more research testing the recommendations. Our proposal directly addresses this concern by testing whether a unique clinical decision support system identifying high risk patients coupled with an advanced pharmacist service directed to the primary physician can address D-AKI and drug dosing for other forms of AKI to improve patient care. Thus, our central goal is to examine the effect of a pharmacist-led intervention on the early detection and management of AKI, progression of and short-term recovery from AKI, and on various AKI-related outcomes.