Improving annual albuminuria testing for individuals with diabetes

Abstract

Background: Annual albuminuria screening detects the early stages of nephropathy in individuals with diabetes. Because early detection of albuminuria allows for interventions that lower the risk of developing chronic kidney disease, guidelines recommend annual testing for all individuals with type 2 diabetes mellitus and for those with type 1 diabetes for at least 5 years. However, at the Eskind Diabetes Clinic at the Vanderbilt University Medical Center, testing occurred less frequently than desired.

Methods: A quality improvement team first analysed the clinic's processes, identifying the lack of a systematic approach to testing as the likely cause for the low rate. The team then implemented two successive interventions in a pilot of patients seen by nurse practitioners in the clinic. In the first intervention, staff used a dashboard within the electronic health record while triaging each patient, pending an albuminuria order if testing had not been done within the past year. In the second intervention, clinic leadership sent daily reminders to the triage staff. A statistical process control chart tracked monthly testing rates.

Results: After 6 months, annual albuminuria testing increased from a baseline of 69% to 82%, with multiple special-cause signals in the control chart.

Conclusions: This project demonstrates that a series of simple interventions can significantly impact annual albuminuria testing. This project's success likely hinged on using an existing workflow to systematically determine if a patient was due for testing and prompting the provider to sign a pended order for an albuminuria test. Other diabetes/endocrinology and primary care clinics can likely implement a similar process and so improve testing rates in other settings. When coupled with appropriate interventions to reduce the development of chronic kidney disease, such interventions would improve patient outcomes, in addition to better adhering to an established quality metric.

Keywords: diabetes mellitus; quality improvement; quality measurement.

Figure 1

Example of a patient dashboard as viewed by triage staff for a patient with diabetes. 2021 Epic Systems Corporation.

Figure 2

Flow chart of an in-clinic visit for a patient with diabetes, focused on albuminuria testing, with potential causes for system failures highlighted by arrows. MA, medical assistant.

Figure 3

Statistical process control charts of the proportion of patients seen by a nurse practitioner (NP) in the clinic, with (A) a fixed mean based on the baseline performance and (B) two separate means based on preintervention and postintervention data.