Improving diabetic nephropathy screening in a primary care clinic: a quality improvement project

Abstract

Background: Diabetes affects people worldwide and multiple organ systems thus end-organ monitoring is needed to reduce mortality and morbidity. Diabetic kidney disease is the leading cause of end-stage renal disease and is easily identified by screening. There is treatment that can prevent complications and further progression to end-stage renal disease. Despite the guidelines, patients at the site, 442 out of 705, did not have annual screening completed as of August 2021. Problem: The primary care site had not applied evidence-based practice guidelines as more than 60% of current patients with diabetes lacked urine protein screening completion from July 2020 to July 2021. Despite evidence indicating that early identification and intervention are critical, the project site did not know how many patients had early markers of chronic kidney disease and who needed treatment. Methods: This project was a single-site quality improvement project focused on increasing ordering and completion of diabetic urine protein screening plan. The project included process development and training regarding the process. The outcomes expected include staff and providers' comfort and understanding regarding process and screening orders, improvement in current screening numbers, and ultimately, treatment of diabetic kidney disease with medications and referral to nephrology if disease was identified. Results: Staff indicated comfort and knowledge with the process and correct ordering process through a survey regarding pre- and post-training. By the completion of this project, as a total 70% of patients (504 out of 720 patients; 62 patients during the 8-week project) have completed screening. Seventeen patients screened positive during the implementation of the process, and two were not on appropriate treatment of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Conclusions: Results indicated that increasing screening was successful based on implementation of a staff protocol, training regarding ordering, and use of EMR reminders to complete screening. Primary care providers have already treated 15 out of 17 patients who screened positive with ACE or ARB for a secondary condition, usually hypertension. This project was beneficial in increasing the focus on screening, which will promote prevention from the development of end-stage renal disease for patients at this clinic long-term.