Identifying opportunities to lower rates of AKI and improve outcomes

描述(申请人提供)：急性肾损伤(AKI)，肾功能的突然下降，是住院患者中常见且重要的问题。AKI与重大的短期和长期发病率和死亡率有关。最近的数据表明，全国住院AKI的发病率呈上升趋势。对AKI的护理完全是支持性的，因为目前还没有有效的治疗方法。因此，找出从一开始就阻止AKI发展的机会至关重要。我们有令人信服的初步数据，来自北加州Kaiser Permanente(一个大型综合医疗保健提供系统，服务约330万人)显示，AKI住院发病率上升的趋势发生了逆转，因此发病率现在正在下降。在拟议的项目中，我们将检验AKI发病率下降与医疗实践中的时间变化相关的假设，例如减少使用肾毒素(目标1)。我们将检验这一假设，即在急诊环境(例如，急诊科和紧急护理诊所)中发现的更多急性KI病例正在社区环境中得到管理；我们将这些病例描述为“社区获得的、社区管理的AKI”(目标2)。最后，我们将确定与复发AKI相关的医疗实践和患者特征，这会导致更高的发病率和累积的有害影响(目标3)。我们的研究团队在开发和分析数据集方面拥有丰富的专业知识，可以全面捕获Kaiser Permanente成员提供的临床护理的细节和精确的临床结果。这些数据集的巨大规模，以及我们可以从以下位置获得的细粒度、关联的个人级别住院和门诊数据 Kaiser Permanente电子病历是我们提议的方法的特别优点。这项研究产生的结果不仅将填补当代AKI流行病学中的重要知识空白(包括社区获得性、社区管理的AKI和复发性AKI)，而且将确定降低AKI风险的机会。由于目前AKI的治疗完全是支持性的，如果AKI发病率的下降与医疗实践模式的具体变化有关，这些变化可以优先在全美范围内广泛测试和实施。在全国范围内降低AKI的发病率将对患者和医疗保健系统都有直接和重要的好处。

DESCRIPTION (provided by applicant): Acute kidney injury (AKI), an abrupt decline in kidney function, is a common and important problem among hospitalized patients. AKI is associated with significant short and long-term morbidity and mortality. Recent data suggest that the incidence of hospitalized AKI is on the rise nationally. Care for AKI is entirely supportive as there are no effective treatments currently. Thus, identifying opportunities to prevent AKI from developing in the first place is critically important. We have compelling preliminary data from Kaiser Permanente Northern California (a large integrated health care delivery system caring for ~3.3 million people) showing a reversal of the rising incidence of hospitalized AKI so that the incidence is now declining. In the proposed project, we will test the hypotheses that the declining AKI incidence correlates with temporal changes in medical practice such as reduced use of nephrotoxins (Aim 1). We will test the hypothesis that more cases of AKI identified in acute- care settings (e.g., emergency department and urgent care clinic) are being managed in the community setting; we describe these cases as "community-acquired, community managed AKI" (Aim 2). Finally, we will determine medical practices and patient characteristics associated with recurrent AKI, which contributes to both higher disease incidence as well as cumulative detrimental effects (Aim 3). Our research team has substantial expertise developing and analyzing datasets that comprehensively capture details of clinical care delivered and precise clinical outcomes among Kaiser Permanente members. The large scale of these datasets, along with the granular, linked individual-level hospitalization and ambulatory data available to us from the Kaiser Permanente electronic medical record, are particular strengths of our proposed approach. The findings generated by this research will not only fill important knowledge gaps in the contemporary epidemiology of AKI (including community-acquired, community-managed AKI and recurrent AKI) but will identify opportunities to reduce the risk of developing AKI. Since care of AKI is entirely supportive at present, if the drop in the incidence of AKI is associated wih specific changes in medical practice patterns, these can be prioritized for testing and implementation on a widespread basis across the United States. A nationwide reduction in the incidence of AKI would have direct and important benefits to both patients and the health care system.