And in this issue: of the CMEJ: Bahji A, Smith J, Danilewitz M, Crockford D, el-Guebaly N, Stuart H. Towards competency-based medical education in addictions psychiatry: a systematic review. . 2021; 12(3) 10.36834/cmej.69739
More recently, authors such as Greenhalgh 4 have drawn attention to the perceived hierarchy of systematic reviews over scoping and narrative reviews. Like Greenhalgh, 4 we argue that systematic reviews are not to be seen as the gold standard of all reviews. Instead, it is important to align the method of review to what the authors hope to achieve, and pursue the review rigorously, according to the tenets of the chosen review type. Sometimes it is helpful to read part of the literature on your topic before deciding on a methodology for organizing and assessing its usefulness. Importantly, whether you are conducting a review or reading reviews, appreciating the differences between different types of reviews can also help you weigh the author’s interpretation of their findings.
In the next section we summarize some general tips for conducting successful reviews.
In 2016 David Cook wrote an editorial for Medical Education on tips for a great review article. 13 These tips are excellent suggestions for all types of articles you are considering to submit to the CMEJ. First, start with a clear question: focused or more general depending on the type of review you are conducting. Systematic reviews tend to address very focused questions often summarizing the evidence of your topic. Other types of reviews tend to have broader questions and are more exploratory in nature.
Following your question, choose an approach and plan your methods to match your question…just like you would for a research study. Fortunately, there are guidelines for many types of reviews. As Cook points out the most important consideration is to be sure that the methods you follow lead to a defensible answer to your review question. To help you prepare for a defensible answer there are many guides available. For systematic reviews consult PRISMA guidelines ; 13 for scoping reviews PRISMA-ScR ; 14 and SANRA 15 for narrative reviews. It is also important to explain to readers why you have chosen to conduct a review. You may be introducing a new way for addressing an old problem, drawing links across literatures, filling in gaps in our knowledge about a phenomenon or educational practice. Cook refers to this as setting the stage. Linking back to the literature is important. In systematic reviews for example, you must be clear in explaining how your review builds on existing literature and previous reviews. This is your opportunity to be critical. What are the gaps and limitations of previous reviews? So, how will your systematic review resolve the shortcomings of previous work? In other types of reviews, such as narrative reviews, its less about filling a specific knowledge gap, and more about generating new research topic areas, exposing blind spots in our thinking, or making creative new links across issues. Whatever, type of review paper you are working on, the next steps are ones that can be applied to any scholarly writing. Be clear and offer insight. What is your main message? A review is more than just listing studies or referencing literature on your topic. Lead your readers to a convincing message. Provide commentary and interpretation for the studies in your review that will help you to inform your conclusions. For systematic reviews, Cook’s final tip is most likely the most important– report completely. You need to explain all your methods and report enough detail that readers can verify the main findings of each study you review. The most common reasons CMEJ reviewers recommend to decline a review article is because authors do not follow these last tips. In these instances authors do not provide the readers with enough detail to substantiate their interpretations or the message is not clear. Our recommendation for writing a great review is to ensure you have followed the previous tips and to have colleagues read over your paper to ensure you have provided a clear, detailed description and interpretation.
Finally, we leave you with some resources to guide your review writing. 3 , 7 , 8 , 10 , 11 , 16 , 17 We look forward to seeing your future work. One thing is certain, a better appreciation of what different reviews provide to the field will contribute to more purposeful exploration of the literature and better manuscript writing in general.
In this issue we present many interesting and worthwhile papers, two of which are, in fact, reviews.
A chance for reform: the environmental impact of travel for general surgery residency interviews by Fung et al. 18 estimated the CO 2 emissions associated with traveling for residency position interviews. Due to the high emissions levels (mean 1.82 tonnes per applicant), they called for the consideration of alternative options such as videoconference interviews.
Understanding community family medicine preceptors’ involvement in educational scholarship: perceptions, influencing factors and promising areas for action by Ward and team 19 identified barriers, enablers, and opportunities to grow educational scholarship at community-based teaching sites. They discovered a growing interest in educational scholarship among community-based family medicine preceptors and hope the identification of successful processes will be beneficial for other community-based Family Medicine preceptors.
Exploring the global impact of the COVID-19 pandemic on medical education: an international cross-sectional study of medical learners by Allison Brown and team 20 studied the impact of COVID-19 on medical learners around the world. There were different concerns depending on the levels of training, such as residents’ concerns with career timeline compared to trainees’ concerns with the quality of learning. Overall, the learners negatively perceived the disruption at all levels and geographic regions.
The impact of local health professions education grants: is it worth the investment? by Susan Humphrey-Murto and co-authors 21 considered factors that lead to the publication of studies supported by local medical education grants. They identified several factors associated with publication success, including previous oral or poster presentations. They hope their results will be valuable for Canadian centres with local grant programs.
Exploring the impact of the COVID-19 pandemic on medical learner wellness: a needs assessment for the development of learner wellness interventions by Stephana Cherak and team 22 studied learner-wellness in various training environments disrupted by the pandemic. They reported a negative impact on learner wellness at all stages of training. Their results can benefit the development of future wellness interventions.
Program directors’ reflections on national policy change in medical education: insights on decision-making, accreditation, and the CanMEDS framework by Dore, Bogie, et al. 23 invited program directors to reflect on the introduction of the CanMEDS framework into Canadian postgraduate medical education programs. Their survey revealed that while program directors (PDs) recognized the necessity of the accreditation process, they did not feel they had a voice when the change occurred. The authors concluded that collaborations with PDs would lead to more successful outcomes.
Experiential learning, collaboration and reflection: key ingredients in longitudinal faculty development by Laura Farrell and team 24 stressed several elements for effective longitudinal faculty development (LFD) initiatives. They found that participants benefited from a supportive and collaborative environment while trying to learn a new skill or concept.
The effect of COVID-19 on medical students’ education and wellbeing: a cross-sectional survey by Stephanie Thibaudeau and team 25 assessed the impact of COVID-19 on medical students. They reported an overall perceived negative impact, including increased depressive symptoms, increased anxiety, and reduced quality of education.
In Do PGY-1 residents in Emergency Medicine have enough experiences in resuscitations and other clinical procedures to meet the requirements of a Competence by Design curriculum? Meshkat and co-authors 26 recorded the number of adult medical resuscitations and clinical procedures completed by PGY1 Fellow of the Royal College of Physicians in Emergency Medicine residents to compare them to the Competence by Design requirements. Their study underscored the importance of monitoring collection against pre-set targets. They concluded that residency program curricula should be regularly reviewed to allow for adequate clinical experiences.
Rehearsal simulation for antenatal consults by Anita Cheng and team 27 studied whether rehearsal simulation for antenatal consults helped residents prepare for difficult conversations with parents expecting complications with their baby before birth. They found that while rehearsal simulation improved residents’ confidence and communication techniques, it did not prepare them for unexpected parent responses.
Peer support programs in the fields of medicine and nursing: a systematic search and narrative review by Haykal and co-authors 28 described and evaluated peer support programs in the medical field published in the literature. They found numerous diverse programs and concluded that including a variety of delivery methods to meet the needs of all participants is a key aspect for future peer-support initiatives.
Towards competency-based medical education in addictions psychiatry: a systematic review by Bahji et al. 6 identified addiction interventions to build competency for psychiatry residents and fellows. They found that current psychiatry entrustable professional activities need to be better identified and evaluated to ensure sustained competence in addictions.
Six ways to get a grip on leveraging the expertise of Instructional Design and Technology professionals by Chen and Kleinheksel 29 provided ways to improve technology implementation by clarifying the role that Instructional Design and Technology professionals can play in technology initiatives and technology-enhanced learning. They concluded that a strong collaboration is to the benefit of both the learners and their future patients.
In his article, Seven ways to get a grip on running a successful promotions process, 30 Simon Field provided guidelines for maximizing opportunities for successful promotion experiences. His seven tips included creating a rubric for both self-assessment of likeliness of success and adjudication by the committee.
Six ways to get a grip on your first health education leadership role by Stasiuk and Scott 31 provided tips for considering a health education leadership position. They advised readers to be intentional and methodical in accepting or rejecting positions.
Re-examining the value proposition for Competency-Based Medical Education by Dagnone and team 32 described the excitement and controversy surrounding the implementation of competency-based medical education (CBME) by Canadian postgraduate training programs. They proposed observing which elements of CBME had a positive impact on various outcomes.
In their work, Interprofessional culinary education workshops at the University of Saskatchewan, Lieffers et al. 33 described the implementation of interprofessional culinary education workshops that were designed to provide health professions students with an experiential and cooperative learning experience while learning about important topics in nutrition. They reported an enthusiastic response and cooperation among students from different health professional programs.
In their article, Physiotherapist-led musculoskeletal education: an innovative approach to teach medical students musculoskeletal assessment techniques, Boulila and team 34 described the implementation of physiotherapist-led workshops, whether the workshops increased medical students’ musculoskeletal knowledge, and if they increased confidence in assessment techniques.
Instagram as a virtual art display for medical students by Karly Pippitt and team 35 used social media as a platform for showcasing artwork done by first-year medical students. They described this shift to online learning due to COVID-19. Using Instagram was cost-saving and widely accessible. They intend to continue with both online and in-person displays in the future.
Adapting clinical skills volunteer patient recruitment and retention during COVID-19 by Nazerali-Maitland et al. 36 proposed a SLIM-COVID framework as a solution to the problem of dwindling volunteer patients due to COVID-19. Their framework is intended to provide actionable solutions to recruit and engage volunteers in a challenging environment.
In Quick Response codes for virtual learner evaluation of teaching and attendance monitoring, Roxana Mo and co-authors 37 used Quick Response (QR) codes to monitor attendance and obtain evaluations for virtual teaching sessions. They found QR codes valuable for quick and simple feedback that could be used for many educational applications.
In Creation and implementation of the Ottawa Handbook of Emergency Medicine Kaitlin Endres and team 38 described the creation of a handbook they made as an academic resource for medical students as they shift to clerkship. It includes relevant content encountered in Emergency Medicine. While they intended it for medical students, they also see its value for nurses, paramedics, and other medical professionals.
The alarming situation of medical student mental health by D’Eon and team 39 appealed to medical education leaders to respond to the high numbers of mental health concerns among medical students. They urged leaders to address the underlying problems, such as the excessive demands of the curriculum.
In the shadows: medical student clinical observerships and career exploration in the face of COVID-19 by Law and co-authors 40 offered potential solutions to replace in-person shadowing that has been disrupted due to the COVID-19 pandemic. They hope the alternatives such as virtual shadowing will close the gap in learning caused by the pandemic.
Canadian Federation of Medical Students' response to “ The alarming situation of medical student mental health” King et al. 41 on behalf of the Canadian Federation of Medical Students (CFMS) responded to the commentary by D’Eon and team 39 on medical students' mental health. King called upon the medical education community to join the CFMS in its commitment to improving medical student wellbeing.
Re: “Development of a medical education podcast in obstetrics and gynecology” 42 was written by Kirubarajan in response to the article by Development of a medical education podcast in obstetrics and gynecology by Black and team. 43 Kirubarajan applauded the development of the podcast to meet a need in medical education, and suggested potential future topics such as interventions to prevent learner burnout.
Response to “First year medical student experiences with a clinical skills seminar emphasizing sexual and gender minority population complexity” by Kumar and Hassan 44 acknowledged the previously published article by Biro et al. 45 that explored limitations in medical training for the LGBTQ2S community. However, Kumar and Hassen advocated for further progress and reform for medical training to address the health requirements for sexual and gender minorities.
In her letter, Journey to the unknown: road closed!, 46 Rosemary Pawliuk responded to the article, Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic, by Gutman et al. 47 Pawliuk agreed that international medical students (IMGs) do not have adequate formal representation when it comes to residency training decisions. Therefore, Pawliuk challenged health organizations to make changes to give a voice in decision-making to the organizations representing IMGs.
In Connections, 48 Sara Guzman created a digital painting to portray her approach to learning. Her image of a hand touching a neuron showed her desire to physically see and touch an active neuron in order to further understand the brain and its connections.
RCT indicates randomized clinical trial; RR, risk ratio. Diamonds indicate heterogeneity; different marker sizes, weights.
MD indicates mean difference; RCT, randomized clinical trial; RR, risk ratio; and USD, US dollars. Diamonds indicate heterogeneity; different marker sizes, weights.
eTable 1. Search Strategy and Result
eTable 2. Reasons for Excluding Full-Text Screening Studies
eTable 3. Inclusion and Exclusion Criteria and Care Bundle or Suggestions for Enrolled Studies
eTable 4. Trial Sequential Analysis With Only Enrolled Randomized Clinical Trials
eTable 5. Sensitivity Analysis
eTable 6. Summary of Certainty of Evidence Assessment
eFigure 1. PRISMA Flow Diagram
eFigure 2. Version 2 of the Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2.0) Assessment of Included Studies and Summary
eFigure 3. Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) Assessment of Included Studies and Summary
eFigure 4. Forest Plot Illustrating the Association of Acute Kidney Injury (AKI) Electronic Alerts (e-Alerts) With Dialysis and Kidney Recovery after AKI
eFigure 5. Forest Plot Illustrating the Association of Acute Kidney Injury (AKI) Electronic Alerts (e-Alerts) With ACEI/ARB Prescription and Fluid Prescription After AKI
eFigure 6. Subgroup Analysis for AKI Progression
eFigure 7. Subgroup Analysis for Mortality
eFigure 8. Subgroup Analysis for Dialysis
eFigure 9. Subgroup Analysis for Kidney Recovery
eFigure 10. Subgroup Analysis for Nephrologist Consultation
eFigure 11. Subgroup Analysis for NSAID Exposure After AKI
eFigure 12. Subgroup Analysis for Hospital Length of Stay
eFigure 13. Subgroup Analysis for Medical Costs
eFigure 14. Subgroup Analysis for AKI Documentation
eFigure 15. Subgroup Analysis for Fluid prescription
eFigure 16. Subgroup Analysis for ACEI/ARB exposure
eFigure 17. Subgroup Analysis for Mortality With Different Follow-Up Period
eFigure 18. Trial Sequential Analysis for Mortality
eFigure 19. Trial Sequential Analysis for AKI Progression
eFigure 20. Trial Sequential Analysis for Dialysis
eFigure 21. Trial Sequential Analysis for Kidney Recovery
eFigure 22. Trial Sequential Analysis for Nephrologist Consultation
eFigure 23. Trial Sequential Analysis for NSAID Exposure After AKI
eFigure 24. Trial Sequential Analysis for AKI documentation
eFigure 25. Funnel Plots
eAppendix 1. Supplemental Method for Trial Sequential Analysis
eAppendix 2. Quality of Included Studies
eAppendix 3. Certainty of Evidence Assessment for AKI Progression
Data Sharing Statement
Sign up for emails based on your interests, select your interests.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Others also liked.
Chen J , Lee T , Chan M, et al. Electronic Alert Systems for Patients With Acute Kidney Injury : A Systematic Review and Meta-Analysis . JAMA Netw Open. 2024;7(8):e2430401. doi:10.1001/jamanetworkopen.2024.30401
© 2024
Question Are electronic alerts (e-alerts) for acute kidney injury (AKI) in the electronic health record associated with patient outcomes or clinical practice patterns?
Findings In this systematic review and meta-analysis of 13 unique studies with 41 837 unique patients, AKI e-alerts were not associated with a lower risk for mortality but were associated with a lower risk for AKI progression compared with standard care. There were associations between e-alerts and clinical practice patterns, including increased nephrologist consultations, dialysis, and AKI documentation and decreased post-AKI exposure to nonsteroidal anti-inflammatory drugs.
Meaning These findings suggest that AKI e-alerts are associated with changes to clinical practice patterns and lower risk for AKI progression, although more research is needed to support this conclusion.
Importance The acute kidney injury (AKI) electronic alert (e-alert) system was hypothesized to improve the outcomes of AKI. However, its association with different patient outcomes and clinical practice patterns remains systematically unexplored.
Objective To assess the association of AKI e-alerts with patient outcomes (mortality, AKI progression, dialysis, and kidney recovery) and clinical practice patterns.
Data Sources A search of Embase and PubMed on March 18, 2024, and a search of the Cochrane Library on March 20, 2024, to identify all relevant studies. There were no limitations on language or article types.
Study Selection Studies evaluating the specified outcomes in adult patients with AKI comparing AKI e-alerts with standard care or no e-alerts were included. Studies were excluded if they were duplicate cohorts, had insufficient outcome data, or had no control group.
Data Extraction and Synthesis Two investigators independently extracted data and assessed bias. The systematic review and meta-analysis followed the PRISMA guidelines. Random-effects model meta-analysis, with predefined subgroup analysis and trial sequential analyses, were conducted.
Main Outcomes and Measures Primary outcomes included mortality, AKI progression, dialysis, and kidney recovery. Secondary outcomes were nephrologist consultations, post-AKI exposure to nonsteroidal anti-inflammatory drugs (NSAID), post-AKI angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker (ACEI/ARB) prescription, hospital length of stay, costs, and AKI documentation.
Results Thirteen unique studies with 41 837 unique patients were included (mean age range, 60.5-79.0 years]; 29.3%-48.5% female). The risk ratios (RRs) for the AKI e-alerts group compared with standard care were 0.96 for mortality (95% CI, 0.89-1.03), 0.91 for AKI stage progression (95% CI, 0.84-0.99), 1.16 for dialysis (95% CI, 1.05-1.28), and 1.13 for kidney recovery (95% CI, 0.86-1.49). The AKI e-alerts group had RRs of 1.45 (95% CI, 1.04-2.02) for nephrologist consultation, 0.75 (95% CI, 0.59-0.95) for post-AKI NSAID exposure. The pooled RR for post-AKI ACEI/ARB exposure in the AKI e-alerts group compared with the control group was 0.91 (95% CI, 0.78-1.06) and 1.28 (95% CI, 1.04-1.58) for AKI documentation. Use of AKI e-alerts was not associated with lower hospital length of stay (mean difference, −0.09 [95% CI, −0.47 to 0.30] days) or lower cost (mean difference, US $655.26 [95% CI, −$656.98 to $1967.5]) but was associated with greater AKI documentation (RR, 1.28 [95% CI, 1.04-1.58]). Trial sequential analysis confirmed true-positive results of AKI e-alerts on increased nephrologist consultations and reduced post-AKI NSAID exposure and its lack of association with mortality.
Conclusions and Relevance In this systematic review and meta-analysis, AKI e-alerts were not associated with a lower risk for mortality but were associated with changes in clinical practices. They were associated with lower risk for AKI progression. Further research is needed to confirm these results and integrate early AKI markers or prediction models to improve outcomes.
Acute kidney injury (AKI) is a common complication in hospitalized patients, leading to increased comorbidities, health care costs, and both short- and long-term mortality. 1 - 3 The introduction of electronic health record systems has enabled early detection of AKI through electronic alerts (e-alerts), considered potential interventions to reduce AKI-related complications and improve outcomes. Consequently, the AKI e-alert system was initially launched in the US and the United Kingdom, later expanding globally. 4 - 7
A 2012 study by Colpaert et al 8 using RIFLE (risk, injury, failure, loss of kidney function, and end-stage kidney disease) criteria showed that AKI e-alerts could enhance short-term renal outcomes and timely interventions. The 27th Acute Disease Quality Initiative consensus also highlighted that “AKI alerts driven by concrete criteria improve early detection and prompt AKI management.” 9 Nevertheless, a 2017 published meta-analysis 6 and subsequent randomized clinical trials (RCTs) and non-RCTs, including Electronic Alerting for Acute Kidney Injury Amelioration (ELAIA)–1 10 and ELAIA-2, 11 questioned their impact on mortality. Despite assumptions about their efficacy in improving AKI outcomes and care, it remains uncertain whether AKI e-alerts, alone or with care bundles, are associated with lower mortality, AKI severity, or the need for kidney replacement or whether they impact clinical practices.
Given the lack of systematic analysis for several associated outcomes, an updated meta-analysis including recently published studies 10 - 12 is warranted. In the present study, we performed a systematic review and meta-analysis, incorporating subgroup analysis and trial sequential analysis using evidence-based medicine methods to assess the association between AKI e-alerts and patient survival, kidney outcomes, clinical practice patterns, and associated outcomes such as medical costs and hospital length of stay (LOS).
This systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA ) statement and checklist. We registered the protocol in PROSPERO ( CRD42024527189 ). Two investigators (J.-J.C. and T.-H.L.) systematically and independently conducted a review of published data on outcomes in patients with AKI e-alerts. A search of PubMed and Embase was performed on March 18, 2024, and the Cochrane Library was searched on March 20, 2024, to identify all relevant studies. Detailed search strategies, including search terms specific to each source, are provided in eTable 1 in Supplement 1 . There were no limitations on language or article types.
After removing duplicates, titles and abstracts were screened by 2 reviewers (J.-J.C. and T.-H.L.) for relevance. Full texts of potentially relevant articles were then reviewed for eligibility. Inclusion criteria required studies to involve adults, compare AKI e-alert groups with non–e-alert groups, and report on any of the primary or secondary outcomes. For eligibility disagreements, a third reviewer (C.-H.C.) was consulted for consensus. Exclusions were made for duplicate cohorts, insufficient outcome data, or absence of a control group.
The 2 investigators (J.-J.C. and T.-H.L.) independently extracted data (author[s], publication year, design, location, AKI care bundle presence, sample size, AKI criteria, mean age, proportion of population that was female) and outcomes from each study. For binary outcomes, participant and event numbers were noted; for continuous outcomes, mean and SD were extracted or calculated from median (IQR). Discrepancies were resolved through discussion with a third investigator (P.-C.F.).
This systematic review and meta-analysis evaluated the differences between AKI e-alerts vs standard care or no e-alerts for patient outcomes or clinical practice patterns. Primary outcomes included mortality and dialysis after AKI (prioritizing 28-day or 30-day, then 60-day, 90-day, and in-hospital mortality and dialysis), AKI stage progression, and kidney recovery after AKI. Secondary outcomes were nephrologist consultations, post-AKI exposure to nonsteroidal anti-inflammatory drugs (NSAIDs), post-AKI angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker (ACEI/ARB) prescription, AKI documentation, post-AKI intravenous fluid prescription, hospital LOS, and medical costs.
In the R meta package, the metabin and metacont functions were used for binary and continuous outcomes, respectively. 13 We applied a random-effects model using the inverse variance method. Between-study variance was estimated using the restricted maximum-likelihood estimator method, while the DerSimonian and Laird method estimated the 95% CI of the effect. We assessed the overall effect using pooled risk ratios (RRs) for binary outcomes and mean differences for continuous outcomes. Heterogeneity was evaluated with the I 2 statistic. Small study bias was examined using funnel plots and the Egger test via the metabias function. 14 Analyses were conducted in R, version 4.2.2 (R Program for Statistical Computing [October 31, 2022]), with 2-sided P < .05 considered statistically significant.
In our analysis, we differentiated studies as RCTs vs non-RCTs. We hypothesized that AKI e-alerts, combined with care recommendations or bundles, might be associated with patient outcomes. To explore this, we performed a subgroup analysis, dividing studies into those using e-alerts with AKI care bundles or recommendations and those using e-alerts alone. For studies reporting mortality outcomes over different time periods, we additionally conducted a subgroup analysis based on the specific time period.
To determine whether the primary outcome conclusions of our meta-analysis were premature, we performed trial sequential analysis (TSA) using TSA software, version 0.9.5.10 beta. 15 A more detailed description is found in eAppendix 1 in Supplement 1 .
Considering that the traditional DerSimonian and Laird method might underestimate between-study heterogeneity and the relatively small number of enrolled studies, we performed sensitivity analyses for binary outcomes using the Hartung-Knapp method and beta-binomial bayesian meta-analysis. The beta-binomial bayesian meta-analysis was conducted using R software and the JAGS (Just Another Gibbs Sampler) program, version 4.3.2 (GNU General Public License). Additionally, we conducted further TSA including only RCTs for both primary and secondary outcomes that showed associations in the conventional meta-analysis.
We assessed the risk of bias using RoB 2.0 (a revised tool to assess risk of bias in randomized trials) 16 and ROBINS-I tool (Risk of Bias in Nonrandomized Studies of Interventions) 17 for included RCTs and non-RCTs, respectively. Two independent reviewers (J.-J.C. and T.-H.L.) assessed the bias according to each domain, and the disagreements between the reviewers were resolved by discussion with another author (P.-C.F.). The quality of evidence was evaluated based on the guidelines of the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) Working Group. 18 , 19
A flowchart of the literature search is provided in eFigure 1 in Supplement 1 ). The electronic database search identified 189 potentially eligible studies from PubMed, 98 from Embase, and 42 from the Cochrane Library. After removing duplicate articles, the remaining 259 articles were screened. After screening the titles and abstracts, the full texts of 34 studies were reviewed to assess their eligibility. After excluding studies for various reasons (eTable 2 in Supplement 1 ), 13 unique studies including 41 837 unique patients 7 , 8 , 10 - 12 , 20 - 27 were included for analysis.
Table 1 summarizes the characteristics of the included studies. Patients’ mean ages varied from 60.5 to 79.0 years, with female representation between 29.3% and 48.5% and male representation between 51.5% and 70.7%. Among the 13 studies, 6 were RCTs, 10 - 12 , 23 , 26 , 27 4 were prospective cohort studies, 7 , 8 , 22 , 25 and 3 were retrospective cohort studies. 20 , 21 , 24 All but 1 study 8 adhered to Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI, with the exception using RIFLE criteria. Additionally, 8 studies 7 , 11 , 12 , 20 - 23 , 25 provided AKI management recommendations or care bundles alongside AKI e-alerts. Further details on inclusion and exclusion criteria and AKI care recommendations are available in eTable 3 in Supplement 1 .
The RoB 2.0 and ROBINS-I assessments indicated varied risk of bias across the studies, with 8 of 13 studies presenting low to moderate risk. For RCTs, overall quality was ranked as low risk for 4 studies (66.7%), 10 - 12 , 26 of some concern for 1 study (16.7%), 27 and of high concern for 1 study (16.7%) 23 (eFigure 2 in Supplement 1 ). For non-RCTs, the overall quality was low risk for 1 study (14.3%), 20 of moderate concern for 3 studies (42.9%), 7 , 8 , 25 and of high concern for 3 studies (42.9%) 21 , 22 , 24 (eFigure 3 in Supplement 1 ) (see details in eAppendix 2 in Supplement 1 ).
In 12 studies with 38 644 participants, 7 , 8 , 10 - 12 , 20 - 23 , 25 - 27 the pooled mortality rate in the e-alert group was 15.7% (3041 of 19 409) and the pooled mortality rate in the control group was 16.7% (3220 of 19 235). Use of AKI e-alerts was not associated with a significant difference in mortality compared with the no use of AKI e-alerts, with substantial heterogeneity (RR, 0.96 [95% CI, 0.89-1.03]; I 2 = 47% [95% CI, 0%-73%]) ( Figure 1 A). There was no significant subgroup difference of pooled effects between RCTs and non-RCTs.
In 5 studies, 10 - 12 , 20 , 25 use of AKI e-alerts was associated with AKI stage progression (RR, 0.91 [95% CI, 0.84-0.99]), with substantial heterogeneity ( I 2 = 70% [95% CI, 23%-88%]). There was a significant subgroup difference of pooled effects between RCTs and non-RCTs ( Figure 1 B). All 5 studies reported AKI progression based on KDIGO criteria. Four studies defined AKI progression as advancing to a higher stage, except for Li et al. 12 Three studies 10 - 12 defined the period as in hospital, while 1 study 20 defined it within 7 days.
Use of AKI e-alerts was associated with dialysis (RR, 1.16 [95% CI, 1.05-1.28]), with substantial heterogeneity ( I 2 = 50% [95% CI, 1%-75%]) and without significant subgroup differences (eFigure 4 in Supplement 1 ). Use of AKI e-alerts was associated with kidney recovery (RR, 1.13 [95% CI, 0.86-1.49]), with high heterogeneity ( I 2 = 98% [95% CI, 97%-99%]) and without significant subgroup difference (eFigure 4 in Supplement 1 ).
Use of AKI e-alerts was associated with nephrologist consultation (RR, 1.45 [95% CI, 1.04-2.02]), with substantial heterogeneity ( I 2 = 95% [95% CI, 93%-97%]) and without significant subgroup difference ( Figure 2 A). Use of AKI e-alerts was associated with lower post-AKI NSAID exposure (RR, 0.75 [95% CI, 0.59-0.95]), with substantial heterogeneity ( I 2 = 69% [95% CI, 11%-89%]) ( Figure 2 B). The pooled RR for post-AKI ACEI/ARB exposure in the AKI e-alerts group compared with the control group was 0.91 (95% CI, 0.78-1.06), with substantial heterogeneity ( I 2 = 72% [95% CI, 19%-90%]) (eFigure 5 in Supplement 1 ). The pooled RR for post-AKI intravenous fluid prescription in the AKI e-alert group compared with the control group was 1.47 (95% CI, 0.86-2.54), with substantial heterogeneity ( I 2 = 97% [95% CI, 95%-98%]) and subgroup difference (eFigure 5 in Supplement 1 ).,
Use of AKI e-alerts was not associated with lower hospital LOS compared with the control group, with a mean difference of −0.09 (95% CI, −0.47 to 0.30) days and substantial heterogeneity ( I 2 = 62% [95% CI, 21%-81%]), without significant subgroup difference ( Figure 3 A). Use of AKI e-alerts was not associated with lower cost compared with the control group, with a mean difference of US $655.26 (95% CI, −$656.98 to $1967.5) and low heterogeneity ( I 2 = 45% [95% CI, 0%-84%]) ( Figure 3 B). Use of AKI e-alerts was associated with greater AKI documentation (RR, 1.28 [95% CI, 1.04-1.58]), with substantial heterogeneity ( I 2 = 94% [95% CI, 90%-96%]) ( Figure 3 C).
Subgroup analysis was performed by dividing enrolled studies into e-alerts in combination with an AKI care bundle or recommendation and those studies without. For AKI progression, studies with AKI e-alerts combined with AKI care bundle or recommendation had a lower RR compared with the non–e-alert groups (RR, 0.85 [95% CI, 0.77-0.93]; P = .03 for subgroup difference test) (eFigure 6 in Supplement 1 ). For the other 3 primary outcomes (mortality, dialysis, and kidney recovery) (eFigures 7-9 in Supplement 1 ) and most secondary outcomes (eFigures 10-15 in Supplement 1 ), there was no significant subgroup heterogeneity detected. Regarding post-AKI ACEI/ARB exposure, AKI e-alerts combined with an AKI care bundle were associated with lower RR (0.78 [95% CI, 0.70-0.88]; P = .002 for subgroup difference test) (eFigure 16 in Supplement 1 ). For studies reporting mortality outcomes over different time periods, there was no significant subgroup difference (eFigure 17 in Supplement 1 ).
A trial sequential analysis on mortality indicated that e-alerts were unlikely to be associated with a 10% risk reduction (eFigure 18 in Supplement 1 ). For AKI stage progression, TSA indicated a premature conclusion (eFigure 19 in Supplement 1 ). For dialysis, TSA show a true-positive finding with sufficient sample size (eFigure 20 in Supplement 1 ) and an uncertain result regarding kidney recovery (eFigure 21 in Supplement 1 ). Trial sequential analysis also supported the results from conventional analysis regarding nephrologist consultations, AKI documentation, and reduced post-AKI NSAID exposure (eFigures 22-24 in Supplement 1 ).
Including only RCTs in the TSA, e-alerts showed a true-positive finding for dialysis, NSAID exposure, and consultation (eTable 4 in Supplement 1 ). Other outcomes were premature, inconclusive, or ineffective. Sensitivity analysis using the Hartung-Knapp method still showed a significantly increased the RR for dialysis. The beta-binomial bayesian meta-analysis also showed a significantly lower RR for NSAID exposure after AKI (eTable 5 in Supplement 1 ).
The funnel plot for all primary and secondary outcomes are provided (eFigure 25 in Supplement 1 ). There was no significant asymmetry observed in the funnel plots. The Egger tests were performed for outcomes with more than 10 studies and found no publication bias for mortality (Egger P = .13), dialysis (Egger P = .63), or nephrologist consultation (Egger P = .26).
The overall certainty of evidence (CoE) varied from moderate to very low. We summarized the results of CoE assessment in eTable 6 in Supplement 1 . The detailed reasons for downgrading are provided in eTable 6 in Supplement 1 and eAppendix 3 in Supplement 1 . We also summarized the results and CoE assessment ( Table 2 ).
This systematic review and meta-analysis highlights 4 key findings. First, AKI e-alerts may be unlikely to be associated with a 10% reduction of risk for mortality in patients with AKI, a finding supported by TSA. Second, AKI e-alerts might be associated with lower RR of AKI progression, but more research is needed to support this conclusion. Third, AKI e-alerts were linked to increased dialysis events. Fourth, AKI e-alerts seem to be associated with different clinical practices (eg, more nephrologist consultations and AKI documentation and less post-AKI NSAID exposure).
Our analysis suggests AKI e-alerts may not be associated with lower RR of mortality but with lower RR of AKI progression, and the pooled effect was associated with heterogeneity. Most studies found AKI e-alerts have a neutral effect on mortality, with exceptions in 2 studies. 10 , 25 Tome et al 25 observed lower mortality with AKI e-alerts plus care recommendations in early-stage AKI, but not in stage 3. Conversely, the ELAIA-1 study 10 noted increased mortality in nonteaching hospitals. The increased primary composite outcome from AKI e-alerts group in nonteaching hospitals was driven by increased mortality, but the dialysis or AKI progression rates were similar across different hospitals. 10 In that study, 10 the authors considered the harm from e-alerts in nonteaching hospitals to be a true effect and postulated several possible mechanisms, including unnecessary intravenous fluid prescription and/or fluid overload, alarm fatigue, and the pressure on clinicians to take potentially harmful actions (which could be prevented by systems in teaching hospitals).
The apparent neutrality, yet underlying heterogeneity, of AKI e-alerts’ association with mortality may result from several factors. First, evaluated AKI e-alert systems use creatinine-based diagnoses, with unreported variations in testing frequency and timing affecting AKI detection. Creatinine level, a delayed and less predictive AKI marker than urine output in patients with critical illness, could affect outcomes. Bianchi et al 28 noted oliguria over 12 hours as a crucial outcome marker, independent of creatinine levels. Second, the AKI e-alert system’s success may depend more on alarm detection and management. The analysis by Shi et al 29 showed physician response to and detection rate of e-alerts might result in different 14-day mortality rates. Third, reducing post-AKI NSAID exposure might explain the lower RR for AKI progression. As previously mentioned, the current limitations of AKI e-alerts may arise from the delayed nature of serum creatinine levels in AKI diagnosis and the heterogeneous effects of AKI e-alerts (which might be raised from different AKI care bundles, different hospitals, or physicians’ responses). Therefore, we suggest that an e-alert system should be integrated with earlier risk stratification methods, such as the renal angina index, 30 , 31 artificial intelligence − based continuous AKI prediction, 32 and care bundle implementation within a clinical decision support system to enhance early diagnosis and management, potentially improving outcomes.
Our analysis suggests that AKI e-alerts may increase post-AKI dialysis events, with more nephrologist consultations and reduced NSAID exposure. The higher dialysis rates in the e-alert group might result from the lack of standardized kidney replacement therapy initiation protocols and increased nephrologist involvement. Despite a lack of significant subgroup differences between RCTs and non-RCTs, 2 non-RCTs 20 , 21 noted higher dialysis rates with e-alerts. Atia et al 20 attributed this to more nephrologist consultations and earlier dialysis initiation. Our analysis found that the e-alert had lower RRs for post-AKI ACEI/ARB prescription. Only Wilson et al 11 reported the effect of e-alerts on post-AKI proton-pump inhibitor prescriptions. In that study, the e-alert group had a higher RR for proton-pump inhibitor therapy discontinuation (RR, 1.26 [95% CI, 1.10-1.45]).
Additionally, AKI e-alerts might reduce AKI stage progression, though with notable subgroup heterogeneity. Studies with AKI e-alerts plus care recommendations showed reduced AKI progression risk (eFigure 6 in Supplement 1 ). However, this finding, according to trial sequential analysis (eFigure 15 in Supplement 1 ), is premature, given the small number of studies reporting this outcome and the reliance on non-RCTs.
Our study has several strengths. It is an updated systematic review and meta-analysis on AKI e-alerts using contemporary evidence-based methods, includes trial sequential analysis, and evaluates the CoE across all outcomes using the GRADE framework. However, limitations exist. First, the scarcity of RCTs led us to combine findings from RCTs, prospective trials, and retrospective studies. Second, few studies examined the impact on hospital LOS, cost, AKI stage progression, post-AKI kidney recovery and ACEI/ARB prescription, limiting our ability to make conclusive statements on these aspects. Third, the evidence lacks exploration of urine output–based AKI e-alerts and early biomarkers for risk stratification, which could enhance early detection and intervention. Fourth, none of the enrolled studies reported major adverse kidney events at 28 and 90 days, which are crucial outcomes after AKI. This leaves the impact of AKI e-alerts and increased dialysis events on long-term outcomes uncertain. Further investigation in these areas is needed.
The current meta-analysis suggests that the implementation of AKI e-alerts might not be associated with a lower risk for mortality but may be associated with different practice patterns (including higher RRs for nephrologist consultations, dialysis, and AKI documentation and lower RRs for post-AKI NSAID exposure). Implementation was associated with a lower RR for AKI progression, but this result was heterogeneous and possibly premature. We recommend that each hospital establish its own AKI e-alert system and individualized AKI management protocol tailored to its specific needs. Additionally, future studies should focus on combining e-alert systems with AKI prediction or early biomarker risk stratification, along with clinical decision support systems or care bundles, which might be beneficial.
Accepted for Publication: July 2, 2024.
Published: August 27, 2024. doi:10.1001/jamanetworkopen.2024.30401
Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Chen JJ et al. JAMA Network Open .
Corresponding Author: Chih-Hsiang Chang, MD, PhD, Department of Nephrology, Linkou Chang Gung Memorial Hospital, No.5 Fusing St, Taoyuan 333, Taiwan ( [email protected] ).
Author Contributions: Drs Chen and Chang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chen, T.-H. Lee, Tsai, C.-C Lee, Chang.
Acquisition, analysis, or interpretation of data: Chen, T.-H. Lee, Chan, Fan, Wu, Tu, Chang.
Drafting of the manuscript: Chen, T.-H. Lee, Chang.
Critical review of the manuscript for important intellectual content: Chan, Tsai, Fan, C.-C. Lee, Wu, Tu, Chang.
Statistical analysis: Chen, Chan, Tsai, Tu, Chang.
Obtained funding: Chang.
Administrative, technical, or material support: T.-H. Lee, Fan, Tu.
Supervision: C.-C. Lee, Wu, Chang.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grants MOHW110-TDU-B-212-124005, MOHW111-TDU-B-212-134005, and MOHW112-TDU-B-212-144005 from the Taiwanese Ministry of Health and Welfare and grant CMRPG5M0181 from Linkou Chang Gung Memorial Hospital (Dr Chang).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 2 .
IMAGES
COMMENTS
3. Identify the article. Start your review by referring to the title and author of the article, the title of the journal, and the year of publication in the first paragraph. For example: The article, "Condom use will increase the spread of AIDS," was written by Anthony Zimmerman, a Catholic priest.
An important role of a review article is to introduce researchers to a field. For this, schematic figures can be useful to illustrate the science being discussed, in much the same way as the first ...
2. Read the article thoroughly: Carefully read the article multiple times to get a complete understanding of its content, arguments, and conclusions. As you read, take notes on key points, supporting evidence, and any areas that require further exploration or clarification. 3. Summarize the main ideas: In your review's introduction, briefly ...
According to Miranda and Garcia-Carpintero , review articles are, on average, three times more frequently cited than original research articles; they also asserted that a 20% increase in review authorship could result in a 40-80% increase in citations of the author. As a result, writing reviews can significantly impact a researcher's citation ...
Show how your research addresses a gap or contributes to a debate; Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic. Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We've written a step-by-step ...
An additional benefit to the authors is that high-quality review articles can often be cited many years after publication (1, 2). The reader of a scientific review article should gain an understanding of the current state of knowledge on the subject, points of controversy, and research questions that have yet to be answered .
The fundamental rationale of writing a review article is to make a readable synthesis of the best literature sources on an important research inquiry or a topic. This simple definition of a review article contains the following key elements: The question (s) to be dealt with.
A well-written review article must summarize key research findings, reference must-read articles, describe current areas of agreement as well as controversies and debates, point out gaps in current knowledge, depict unanswered questions, and suggest directions for future research ( 1 ). During the last decades, there has been a great expansion ...
A good review article provides readers with an in-depth understanding of a field and highlights key gaps and challenges to address with future research. Writing a review article also helps to expand the writer's knowledge of their specialist area and to develop their analytical and communication skills, amongst other benefits.
Lit Review Article: Research Article: Does What? Reports on the work of others. Reports on original research. Purpose: To examine and evaluate previous literature. To test a hypothesis and/or make an argument. May include a short literature review to introduce the subject.
A good review article provides readers with an in-depth understanding of a field and highlights key gaps and challenges to address with future research. Writing a review article also helps to expand the writer's knowledge of their specialist area and to develop their analytical and communication skills, amongst other benefits. Thus, the ...
For an article review, your task is to identify, summarize, and evaluate the ideas and information the author has presented. You are being asked to make judgments, positive or negative, about the content of the article. The criteria you follow to do this will vary based upon your particular academic discipline and the parameters of your ...
The main purpose of a review article is to reconcile conflicting findings and suggest novel and new directions for a given field of research with reference to methodology, theory, constructs and contexts for others to examine using quantitative or qualitative methods ( Canabal and White, 2008, Hao et al., 2019 ).
A review article can also be called a literature review, or a review of literature. It is a survey of previously published research on a topic. It should give an overview of current thinking on the topic. And, unlike an original research article, it will not present new experimental results. Writing a review of literature is to provide a ...
Read at least five highquality chapters on a similar topic to make yours better. STEP 2. Gather and read about 50 -100 original articles on a topic within your scientific field. STEP 3. Write down ...
Before getting started on the critique, it is important to review the article thoroughly and critically. To do this, we recommend take notes, annotating, and reading the article several times before critiquing. As you read, be sure to note important items like the thesis, purpose, research questions, hypotheses, methods, evidence, key findings ...
This is why the literature review as a research method is more relevant than ever. Traditional literature reviews often lack thoroughness and rigor and are conducted ad hoc, rather than following a specific methodology. Therefore, questions can be raised about the quality and trustworthiness of these types of reviews.
Tips To Write An Review Article Fast. Writing a review article quickly without sacrificing quality might seem like a tall order, but with the right approach, it's entirely achievable. Clearly Define Your Research Question. Clearly define your research question. A focused question not only narrows down the scope of your literature search but ...
When searching the literature for pertinent papers and reviews, the usual rules apply: be thorough, use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and. look at who has cited past relevant papers and book chapters.
Research Article Review. Distinguished by its focus on research methodologies, a research article review scrutinizes the techniques used in a study and evaluates them in light of the subsequent analysis and critique. For instance, when reviewing a research article on the effects of a new drug, the reviewer would delve into the methods employed ...
A review article is a comprehensive summary of the current understanding of a specific research topic and is based on previously published research. Unlike research papers, it does not contain new results, but can propose new inferences based on the combined findings of previous research. Types of review articles
Many research disciplines feature high-impact journals that are dedicated outlets for review papers (or review-conceptual combinations) (e.g., Academy of Management Review, Psychology Bulletin, Medicinal Research Reviews).The rationale for such outlets is the premise that research integration and synthesis provides an important, and possibly even a required, step in the scientific process.
Systematic reviews are characterized by a methodical and replicable methodology and presentation. They involve a comprehensive search to locate all relevant published and unpublished work on a subject; a systematic integration of search results; and a critique of the extent, nature, and quality of evidence in relation to a particular research question.
The first step in reading a scholarly article is to read the abstract or summary of the article. Abstracts are always found at the beginning of an article and provide a basic summary or roadmap to the article. The abstract also introduces the purpose of the article. Take a few minutes to carefully read the abstract of the practice article.
Brown M., Nyberg A. J., Weller I., Strizver S. D. 2022. Pay information disclosure: Review and recommendations for research spanning the pay secrecy-pay transparency continuum. Journal of Management, 48: 1661-1694. Crossref. Web of Science ... The art of writing a review article. Journal of Management, 35: 1312-1317. Crossref. Web of Science ...
Bibliographic coverage of current research focused on social work, human services, and related areas, including social welfare, social policy, and community development. Abstracts and indexes serials, journal articles, dissertations, and more. Interdisciplinary Databases for Peer-reviewed Literature. APA PsycInfo (Psychological Abstracts)
In this editorial we survey the various forms review articles can take. As well we want to provide authors and reviewers at CMEJ with some guidance and resources to be able write and/or review a review article. ... Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review. Medical Education ...
This research provides an in-depth examination of diabetes-related hospital readmissions and reviews recent studies (2015-2023) to understand the characteristics, risk factors, and potential outcomes for re-admitted diabetes patients. The study identified 21 articles that met the inclusion criteria to provide valuable insights and analyze risk ...
This systematic review and meta-analysis highlights 4 key findings. First, AKI e-alerts may be unlikely to be associated with a 10% reduction of risk for mortality in patients with AKI, a finding supported by TSA. Second, AKI e-alerts might be associated with lower RR of AKI progression, but more research is needed to support this conclusion.
Objective: To describe the profile of Streptococcus pneumoniae, identify research gaps, and provide in-depth insights into various aspects related to the pathogen. Methods: Google Scholar, PubMed, and ScienceDirect were searched for all studies on the pneumococcus in Ghana that reported on specimen collected, population and sample size, carriage prevalence, incidence of pneumococcal diseases ...