Improving Chronic Kidney Disease Screening in Adults Living with Diabetes in the West Oahu Community of Hawaii

Background: Nearly 1 in 3 diabetic patients have chronic kidney disease (CKD). However, many of these patients are asymptomatic and undiagnosed until advanced stages of disease. Thus, routine screening, early detection, and treatment are crucial for reducing the morbidity and mortality of CKD. Kidney health evaluation fulfillment is defined as having both estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR) testing done within the measurement year. Currently, the national CKD screening rate is approximately 40% and even lower for marginalized groups. Similarly, we found the screening rate in the diabetic population at a primary care practice in West Oahu, which serves a large percentage of Native Hawaiians and Pacific Islanders, to be relatively low. The goal of this quality improvement (QI) project was to identify reasons for care gaps and implement patient outreach interventions to improve the screening rate in this population.

Methods: Chart review of the electronic medical records of 315 diabetic patients at this primary care office was conducted. Dates and results of the most recent eGFR and uACR lab tests were recorded. Patients were then determined to be screened or unscreened. According to screening criteria, patients older than 75, receiving hospice/palliative care, or diagnosed with end-stage renal disease (ESRD) or stage 5 CKD were excluded. Based on the most common reasons for care gaps, three patient-centered outreach interventions were implemented over 6 months. Two text message reminders about overdue lab tests were sent to unscreened patients, followed by two phone call reminders, and finally, two text message reminders to alternative phone numbers, if available. Chart reviews were conducted between each intervention to identify newly-screened patients.

Results: The baseline screening rate was found to be 52.4%. However, 57 patients did not meet inclusion criteria. Of the remaining patients, 58.1% fulfilled the criteria for CKD screening. The most common reason for care gaps among unscreened patients was due to incompleted uACR testing within the last 12 months (79.8%). Incomplete eGFR was the second most common (49%). Text message reminders, phone call reminders, and texts to alternative numbers increased screening rates by 10.8%, 5.5%, and 2.3%, respectively. At the end of 6 months, the screening rate increased by 29.4%, totaling 81.8% of patients screened for CKD.

Conclusion: Increased screening allows for earlier detection and treatment of CKD, thereby reducing its mortality and morbidity. Our findings suggest that suboptimal baseline CKD screening rates for diabetic patients can be increased through patient-centered interventions, with text messages being the most effective and efficient. Secondary analyses may be conducted to determine long-term outcomes, or if screening status is associated with other care measures or features of this population. While these initial results and interventions are limited to this setting, the results can be applied to other areas of primary care and expanded to include a wider scope of patients. Provider-centered interventions, either alone or in combination with patient-centered approaches, may also be a potential area of future research in increasing CKD screening rates.

Target Audience: Physicians, Residents, Medical Students

References:
Ferrè S, Storfer-Isser A, Kinderknecht K, Montgomery E, Godwin M, Andrews A, Dunning S, Barton M, Roman D, Cuddeback J, Stempniewicz N, Chu CD, Tuot DS, Vassalotti JA. Fulfillment and Validity of the Kidney Health Evaluation Measure for People with Diabetes. Mayo Clin Proc Innov Qual Outcomes. 2023 Aug 29;7(5):382-391. doi: 10.1016/j.mayocpiqo.2023.07.002. PMID: 37680649; PMCID: PMC10480072. https://www.mcpiqojournal.org/article/S2542-4548(23)00041-3/fulltext
United States Renal Data System. 2022 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, US Department of Health and Human Services; 2022. Accessed September 1, 2023. https://usrds-adr.niddk.nih.gov/2022
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