Proper Screening and Diagnosing of Diabetic Kidney Disease: A Quality Improvement Initiative in Primary Care Setting for the Underinsured

Background / significance of problem.  Over 23 million Americans have diabetes. Diabetic nephropathy, the single leading cause of end stage renal disease, occurs in 20 to 40% of all patients with diabetes.  In primary care settings, rates for screening and diagnosis of diabetic kidney disease are low, and infrastructure is lacking that could improve patient outcomes. 

 

Clinical question/project objectives.  Will implementation of a quality improvement process in a primary care clinic for the underinsured improve screening, diagnosis, and treatment of diabetic kidney disease?  The project will address three objectives: 1) develop and implement a sustainable quality improvement process in a primary care setting; 2) evaluate diabetic kidney disease screening and; 3) evaluate the prevalence rate of diabetic kidney disease diagnosis.

 

Search of literature / best evidence. According to Healthy People 2020 (2013), only 23.1% of diabetics over age 65 received appropriate evaluation for diabetic kidney disease.  Akbari et al. (2004) improved the evaluation of diabetic kidney disease from 22.4% to 85.1% with provider education within a primary care clinic. Quality improvement is well established in acute care settings with favorable outcomes but is lacking in primary care settings (Talyor, Peikes, Genevro, & Meyers, 2013); only 10% of primary care settings are accredited by the National Committee for Quality Assurance. Incorporating a quality improvement process in primary care could provide the best opportunity for proper screening and diagnosis of diabetic kidney disease.  

 

Integration into practice.  Diabetic kidney disease screening and diagnosis data will be collected from 503 adult non-pregnant patients with type 1 and type 2 diabetes pre and post intervention via medical records audit. A quality improvement theoretical framework will be utilized to implement an educational intervention to improve practice.  A decision tree, developed from current practice guidelines of the American Diabetes Association and the National Kidney Foundation, will guide primary care providers in ordering urine microalbumin, GFR, serum creatinine, and dilated eye exam to appropriately diagnose diabetic kidney disease.    

 

Implications for practice.  Dependent t-tests on outcome variables will determine if the intervention was successful in improving provider screening and diagnosing of diabetic kidney disease.  The educational intervention has the potential to address the Healthy People 2020 chronic kidney disease goals and the clinical guideline objectives of proper screening and diagnosis of diabetic kidney disease in primary care.