Acute Kidney Injury in Care Transitions: The ACT Pragmatic Trial

About This Grant

PROJECT SUMMARY/ABSTRACT Acute kidney injury (AKI) is an abrupt loss of kidney function that affects 1 in 5 hospitalized patients. AKI survivors experience a 1.5-2.5-fold higher risk of chronic kidney disease (CKD), a 1.4-fold higher risk of cardiovascular disease, and 50% of affected individuals are readmitted within 1 year. Despite these grave sequelae, the care of non-dialysis-dependent AKI survivors is inadequate. One-third of patients fail to receive basic kidney health follow-up (i.e., laboratory assessment of kidney function and a visit with a clinician). 87% of AKI survivors use nephrotoxic medications in the 3 years after discharge, which independently increases the risk for CKD. These gaps are especially prominent in the 20% of AKI survivors from rural settings who experience health disparities including transportation barriers, a higher comorbidity burden, decreased health literacy, and reduced access to nephrology specialist care. Addressing these gaps in care facilitates prognostication, decision making, medication reconciliation and supportive care which can limit AKI complications. We therefore developed the AKI in Care Transitions (ACT) program, a multidisciplinary bundled care delivery model tailored to individual prognosis. AKI survivors are risk-stratified according to post-discharge prognosis. Those at the lowest risk are provided access to informational resources about AKI. Patients at moderate risk receive kidney health education before discharge from nurses and coordinated follow-up in primary care with a provider and a pharmacist in the 7-14 days after discharge. The highest-risk patients are provided with home monitoring technology (e.g., blood pressure cuff, tablet for symptom assessments) and followed remotely by nephrology specialists for up to 90 days. Pilot testing in an academic medical center demonstrated feasibility, a significant increase in timely and complete follow-up, improved medication reconciliation, and a decreased incidence of kidney disease progression. This proposal extends ACT to rural settings to address the overall goal of creating effective, patient-centered, scalable care delivery models that improve health outcomes for all AKI survivors. We will test the impact of ACT on health outcomes and processes of care (e.g., kidney disease progression, excess days in acute care, adverse drug events, guideline-concordant care) in rural patients using a pragmatic cluster randomized trial conducted in the Mayo Clinic Health System (MCHS; Aim 1). We will then richly characterize the rural AKI survivor experience including illness burden, treatment burden, and patient capacity (Aim 2a) and assess the impact of ACT (Aim 2b) using qualitative data gathered from rural patients at MCHS and the University of Maryland Medical System. This innovative proposal leverages digital health and the multidisciplinary team to improve outcomes and reduce health disparities for AKI survivors in rural settings.