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Impact on clinical practice of updated guidelines on iodinated contrast material: CINART
E C Nijssen1, P J Nelemans2, R J Rennenberg3
1Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands. estelle.nijssen@mumc.nl.
Insights
Updated guidelines for iodinated contrast material no longer recommend routine prophylactic hydration for most patients. This change significantly reduced complications, hospitalizations, and costs associated with contrast procedures.
Area of Science:
- Radiology
- Nephrology
- Health Economics
Background:
- Intravenous prophylactic hydration was standard to prevent contrast-induced nephropathy.
- Recent guideline updates de-emphasize routine prophylaxis for most patients undergoing contrast procedures.
- The impact of these guideline changes on clinical practice requires evaluation.
Purpose of the Study:
- To assess the clinical and economic consequences of updated guidelines on contrast material use.
- To quantify reductions in complications, hospitalizations, and costs post-guideline update.
- To provide a model for local estimation of impact.
Main Methods:
- Retrospective observational study (CINART project).
- Included elective procedures with iodinated contrast in patients formerly and currently eligible for prophylaxis.
- Calculated relative reductions in complications, hospitalizations, and costs.
Main Results:
- 1992 procedures analyzed; 1808 formerly eligible, 184 currently eligible.
- Maastricht UMC+ observed significant reductions: 89% fewer complications, 93% fewer hospitalizations, 91% lower costs.
- Similar reductions are anticipated in other medical centers.
Conclusions:
- Updated guidelines have a demonstrable positive impact on patient care, hospital efficiency, and healthcare budgets.
- Clinical practice variations necessitate local impact assessments.
- The study provides a framework for evaluating guideline implementation.
Objective:
Guidelines on safe use of iodinated contrast material recommend intravenous prophylactic hydration to prevent post-contrast adverse (renal) effects. Recently, guidelines have been updated and standard prophylaxis is no longer recommended for the majority of patients. The current study aims to evaluate the consequences for clinical practice of the updated guidelines in terms of complications, hospitalisations, and costs.
Methods:
The Contrast-Induced Nephropathy After Reduction of the prophylaxis Threshold (CINART) project is a retrospective observational study. All elective procedures with intravascular iodinated contrast administration at Maastricht University Medical Centre (UMC+) in patients aged > 18 years, formerly eligible for prophylaxis (eGFR 30-44 ml/min/1.73 m2 or eGFR 45-59 ml/min/1.73 m2 in combination with diabetes or > 1 predefined risk factor), and currently eligible for prophylaxis (eGFR < 30 ml/min/1.73 m2) were included. Data were used to calculate relative reductions in complications, hospitalisations, and costs associated with standard prophylactic intravenous hydration. CINART is registered with Clinicaltrials.gov: NCT03227835.
Results:
Between July 1, 2017, and July 1, 2018, 1992 elective procedures with intravascular iodinated contrast in patients formerly and currently eligible for prophylaxis were identified: 1808 in patients formerly eligible for prophylaxis and 184 in patients currently eligible for prophylaxis. At Maastricht UMC+, guideline updates led to large relative reductions in numbers of complications of prophylaxis (e.g. symptomatic heart failure; - 89%), extra hospitalisations (- 93%), and costs (- 91%).
Conclusion:
Guideline updates have had a demonstrable impact on daily clinical practice benefiting patient, hospital, and health care budgets. Clinical practice varies between institutions and countries; therefore, a local estimation model is provided with which local impact on costs, hospitalisations, and complications can be calculated.
Key Points:
• Clinical practice guidelines recommend prophylactic intravenous hydration to prevent post-contrast adverse outcomes such as contrast-induced acute kidney injury. • Clinical practice guidelines have recently been updated, and standard prophylaxis is no longer recommended for the majority of patients. • The guideline updates have a large impact on daily clinical practice: relative reductions at Maastricht UMC+ were - 89% prophylaxis complications, - 93% hospitalisations, and - 91% costs, and similar reductions are expected for Dutch and adherent European medical centres.
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