Improving diabetic kidney disease screening in a VA resident primary care clinic: a quality improvement initiative

Annual screening for diabetic kidney disease (DKD) with serum creatinine and albuminuria is recommended by multiple clinical guidelines but screening rates remain low nationwide (<50%). The Veterans Health Administration has implemented quality improvement (QI) interventions that resulted in a significantly higher national DKD screening rate of 63%. However, the rate in the resident primary care clinic at the Iowa City Veterans Affairs (ICVA) was only 41%, suggesting that these interventions may not be as effective in resident clinics. Residents have unique schedules and time demands, thus QI initiatives targeting this transient physician population need to be appropriately tailored.

An interprofessional working group aimed to increase the screening rate for DKD in the resident clinic from 41% to 65% over 8 months using Lean methodology. This non-randomised, prospective QI project was conducted at the resident primary care clinic at the ICVA, which serves approximately 3000 Veterans (including 750 with diabetes). Two sequential interventions were implemented: (1) a national electronic health record reminder and (2) a tailored, resident-specific, multifaceted approach involving incentives, gamification, workflow improvements, audit and feedback, and benchmarking. The primary outcome was monthly percentage of Veterans with both a urine albumin-to-creatinine ratio and serum creatinine tested in the past year. The process measure was weekly percentage of eligible Veterans tested for albuminuria within 1 day before or 7 days after a primary care appointment.

The percentage of compliant Veterans in the resident primary care clinic increased from 41% (239/590) in June 2023 to 66% (395/603) by March 2024. Weekly screening rates of eligible Veterans rose from 16% to 48%. The biggest improvement was seen after the resident-specific interventions.

This project demonstrates the need for and effectiveness of tailored, resident-specific implementation strategies to achieve QI aims among these physicians.