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

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.