From the 2022 HVPA National Conference
Sara Cohen MD (Loyola University Medical Center), Michael Stokas MD
Diabetic nephropathy is the leading cause of end stage renal disease and affects up to 40% of type 1 and type 2 diabetic patients. An albumin-to-creatinine ratio from a morning urine sample seems to best predict diabetic kidney disease progression. If moderate albuminuria is detected, strict glycemic control and angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) therapy can prevent progression to overt nephropathy and promote albuminuria remission. The JNC7, the National Kidney Foundation (NKF), and the American Diabetes Association (ADA) recommend annual albumin-to-creatinine ratio measurement for adults with type 1 and type 2 diabetes. In our continuity clinic comprised of four residents, the baseline screening rate for urine albumin-to-creatinine ratio was 56% of all diabetic patients. This presented an opportunity for improvement.
In our resident continuity clinic, we aimed to increase the annual urine albumin-to-creatinine screening rate from 56% to 80% of all diabetic patients over 6 months.
To increase our albuminuria screening rate, we created a “SmartPhrase” in the electronic medical record (EMR) that was entered into each clinic progress note. This SmartPhrase was a typed shortcut that populated a patient’s most recent hemoglobin A1c and urine albumin-to-creatinine ratio, if any (Figure 1). The SmartPhrase contained a question that required an answer in order to electronically sign the note and visit. If the SmartPhrase demonstrated a hemoglobin A1c consistent with diabetes and an albumin-to-creatinine ratio that was over one year old, it would prompt the residents to order a new microalbumin-to-creatinine test for that patient. We received individual resident performance data every 2-3 months, which comprised 3 PDSA cycles. At these times, we compiled our individual screening data to determine our combined screening rate for microalbumin-to-creatinine ratio. We used these results to reevaluate our intervention after each PDSA cycle.
After the first PDSA cycle, the total albumin-to-creatinine screening rate increased to 77%. No adjustments to the intervention were made. After the second PDSA cycle, the screening rate increased 82%, meeting our goal. No adjustments were made. After the final PDSA cycle, the screening rate decreased to 68%. Figure 2 demonstrates this trend over time.
An EMR SmartPhrase typed into progress notes prompted review of albuminuria screening history and thus increased the albuminuria screening rate among diabetic patients in our clinic. We did meet our goal screening rate of at least 80% after the second PDSA cycle, but our percentage declined after the third cycle. The limitations of this intervention included remembering to enter the SmartPhrase into every note and the ability to copy forward the SmartPhrase with outdated data. These limitations likely contributed to the late decline in screening rate. A solution could be to build the EMR to review a patient’s problem list for diabetes and review albumin-to-creatinine screening history. If the patient is diabetic, the EMR would prevent the physician from signing the encounter unless an albumin-to-creatinine ratio was ordered in the last year.
This initiative improved the quality of patient care in our continuity clinic because a greater percentage of diabetic patients were screened annually for albuminuria, which allowed for earlier detection and treatment with ACE inhibitors and ARBs, thus preventing progression to overt diabetic nephropathy.