A Nurse Practitioner-Led Interprofessional Provider Education Intervention to Improve Diabetic Kidney Disease Screening in an Under-insured Population

Diabetes is the leading cause of chronic kidney disease (CKD), accounting for 44% of all new cases of kidney failure. Healthy People 2020 reports only 23% of persons with type 1 or type 2 diabetes receive proper screening for CKD, defined as annual serum creatinine, microalbumin, A1c, lipids and dilated eye exam.  Nurse practitioners (NPs) in primary care have opportunities to increase screening rates for CKD. The purpose of this study is to answer the clinical question: Will primary care providers for the underinsured improve screening and diagnosis of CKD after an NP-led educational intervention over three months? The study occurred in three phases:  baseline chart audit, educational intervention for primary care providers led by the NP, and post-intervention chart audit. Inclusion criteria for chart audit were: non-pregnant patients with type 1 or type 2 diabetes. A cohort of N=453 diabetic patient charts meeting criteria were audited over 18-months for baseline data. Demographic characteristics were: 71% White, 13% Black, 3% Hispanic, 8% Multicultural or Other, < 1% Asian or Indian; mean age 54 years; mean BMI 37; 54% female, 45% male; 74% had hypertension.  Analysis of all tests ordered (serum creatinine, microalbumin, A1c, lipids and dilated eye exam) yielded a 21% screening rate. Evidence of documented CKD diagnosis was 4%. Using quality improvement processes as a theoretical framework, the NP implemented a one-hour educational session and 6 shorter follow-up sessions with an interprofessional mix (MD, NP, PA) of 15 primary care providers to facilitate awareness of chart audit findings, standards of care, and goals. A decision tree, developed from current American Diabetes Association and National Kidney Foundation practice guidelines, guided providers in ordering screenings to diagnose CKD. Preliminary second chart audit data analysis of tests ordered 3 months post-intervention on a cohort subset (N= 103) yielded a 64% screening rate (defined as orders for or lab value for microalbumin, or diagnosis of Microalbuminuria). Evidence of documented CKD diagnosis was 12%. Analysis is ongoing, but preliminary results show promise that NP-led educational interventions with primary care providers can improve screening and diagnosis rates for CKD in vulnerable populations with diabetes.