Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
On the 31st of July 2019, three research articles were published which described the evaluation of a digitally-enabled care pathway for patients with Acute Kidney Injury (AKI) implemented at the Royal Free Hospital (RFH) in London[1–3]. Analysis was comprehensive: across three manuscripts we clearly report all the outcomes we identified, including impacts on processes of care, clinical outcomes, healthcare costs, staff experiences and unforeseen consequences.
An article in BMJ News (2nd of August) reported only some of these findings, resulting in an unbalanced summary. We offer clarification here.
As clearly stated in our papers: for emergency department patients, trends in recovery of renal function and renal or ICU admission improved significantly at both the RFH and the comparator site (where concurrent improvement initiatives were taking place). However, pathway implementation was associated with significant improvements in the speed and reliability of AKI detection and a reduction in the time to treatment of nephrotoxicity. Qualitative evaluation found that the care pathway expedited rapid intervention for deteriorating patients and may have enabled more constructive planning of end of life care due to the earlier detection and alerting of deterioration. However real time alerting created anxiety, particularly for some junior staff because of increasing numbers of priority patients, information overload (in part exacerbated by the false positive alerts associated with the mandated NHS England AKI algorithm) and lack of training in / ambivalence about the benefits of intervening at an earlier stage. Mean healthcare costs per patient admission were reduced by £2,123.
The results have also helped inform a scientific question: whether rapid specialist intervention for existing AKI improves outcomes. It appears that - at least in terms of clinical outcomes - the impact of such an approach may not exceed that of other quality improvement initiatives and adds to the growing scientific consensus that predicting and preventing the damage itself may be the most effective approach. It was for this reason that a quite separate piece of work was performed[4], to which the BMA News article refers. However, this research was unrelated to the results published on the RFH care pathway and used a large US dataset in its development.
The BMJ’s headline that the app “had no clinical benefit” and the conclusion that ”the study will be a serious setback for the idea that digital apps can transform medicine” therefore both misrepresents our results and is precipitous. Clearly, further evidence from larger, multi-site evaluation, with longer follow up is required to clarify any added value of the integration of this digital innovation into care pathways. However, for the first time, our research highlights the conditions that need to be in place when such innovations are introduced. At a time when digital technology is being enthusiastically embraced by policy makers, it’s vital to demonstrate the importance of robust but timely evaluations which examine the extent to which desired benefits are achieved for patients, the various impacts on the NHS, as well as unanticipated direct and indirect consequences. A balanced approach to reporting research findings is also key to ensuring productive debate.
References
1 Connell A, Montgomery H, Martin P, et al. Evaluation of a digitally-enabled care pathway for acute kidney injury management in hospital emergency admissions. npj Digital Medicine 2019;2:67.
2 Connell A, Raine R, Martin P, et al. Implementation of a Digitally Enabled Care Pathway (Part 1): Impact on Clinical Outcomes and Associated Health Care Costs. J Med Internet Res 2019;21:e13147.
3 Connell A, Black G, Montgomery H, et al. Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals. J Med Internet Res 2019;21:e13143.
4 Tomasev N, Glorot X, Rae JW, et al. A clinically applicable approach to continuous prediction of future acute kidney injury. Nature 2019;572:116–9.
Competing interests:
HM, RR and GR are all employed as Professors at University College London, and CL at University College London Hospitals. All are paid to consult for Deepmind Health.
05 August 2019
Hugh Montgomery
Professor of Intensive Care Medicine
Prof Rosalind Rayne, Prof Geraint Rees, Dr Chris Laing
University College London
Dept Medicine, University College London, Gower Street, London W1C
Re: App to help spot acute kidney injury had no clinical benefits, study finds
On the 31st of July 2019, three research articles were published which described the evaluation of a digitally-enabled care pathway for patients with Acute Kidney Injury (AKI) implemented at the Royal Free Hospital (RFH) in London[1–3]. Analysis was comprehensive: across three manuscripts we clearly report all the outcomes we identified, including impacts on processes of care, clinical outcomes, healthcare costs, staff experiences and unforeseen consequences.
An article in BMJ News (2nd of August) reported only some of these findings, resulting in an unbalanced summary. We offer clarification here.
As clearly stated in our papers: for emergency department patients, trends in recovery of renal function and renal or ICU admission improved significantly at both the RFH and the comparator site (where concurrent improvement initiatives were taking place). However, pathway implementation was associated with significant improvements in the speed and reliability of AKI detection and a reduction in the time to treatment of nephrotoxicity. Qualitative evaluation found that the care pathway expedited rapid intervention for deteriorating patients and may have enabled more constructive planning of end of life care due to the earlier detection and alerting of deterioration. However real time alerting created anxiety, particularly for some junior staff because of increasing numbers of priority patients, information overload (in part exacerbated by the false positive alerts associated with the mandated NHS England AKI algorithm) and lack of training in / ambivalence about the benefits of intervening at an earlier stage. Mean healthcare costs per patient admission were reduced by £2,123.
The results have also helped inform a scientific question: whether rapid specialist intervention for existing AKI improves outcomes. It appears that - at least in terms of clinical outcomes - the impact of such an approach may not exceed that of other quality improvement initiatives and adds to the growing scientific consensus that predicting and preventing the damage itself may be the most effective approach. It was for this reason that a quite separate piece of work was performed[4], to which the BMA News article refers. However, this research was unrelated to the results published on the RFH care pathway and used a large US dataset in its development.
The BMJ’s headline that the app “had no clinical benefit” and the conclusion that ”the study will be a serious setback for the idea that digital apps can transform medicine” therefore both misrepresents our results and is precipitous. Clearly, further evidence from larger, multi-site evaluation, with longer follow up is required to clarify any added value of the integration of this digital innovation into care pathways. However, for the first time, our research highlights the conditions that need to be in place when such innovations are introduced. At a time when digital technology is being enthusiastically embraced by policy makers, it’s vital to demonstrate the importance of robust but timely evaluations which examine the extent to which desired benefits are achieved for patients, the various impacts on the NHS, as well as unanticipated direct and indirect consequences. A balanced approach to reporting research findings is also key to ensuring productive debate.
References
1 Connell A, Montgomery H, Martin P, et al. Evaluation of a digitally-enabled care pathway for acute kidney injury management in hospital emergency admissions. npj Digital Medicine 2019;2:67.
2 Connell A, Raine R, Martin P, et al. Implementation of a Digitally Enabled Care Pathway (Part 1): Impact on Clinical Outcomes and Associated Health Care Costs. J Med Internet Res 2019;21:e13147.
3 Connell A, Black G, Montgomery H, et al. Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals. J Med Internet Res 2019;21:e13143.
4 Tomasev N, Glorot X, Rae JW, et al. A clinically applicable approach to continuous prediction of future acute kidney injury. Nature 2019;572:116–9.
Competing interests: HM, RR and GR are all employed as Professors at University College London, and CL at University College London Hospitals. All are paid to consult for Deepmind Health.