insight - Medical diagnostics - # Chronic Kidney Disease Screening Gaps in Primary Care

Widespread Underutilization of Albuminuria Quantification Testing Following Abnormal Urine Dipstick Results in Primary Care

Q: What are the potential consequences of this widespread underutilization of albuminuria quantification testing on patient outcomes and the management of chronic kidney disease?

The underutilization of albuminuria quantification testing has significant implications for patient outcomes and the overall management of chronic kidney disease (CKD). First and foremost, the failure to follow up on abnormal urine dipstick results can lead to delayed diagnosis and treatment of CKD. Early identification of albuminuria is crucial, as it serves as a key prognostic indicator for kidney function decline and cardiovascular risk. Without timely intervention, patients may progress to more advanced stages of CKD, which are associated with increased morbidity, mortality, and healthcare costs. Moreover, the lack of follow-up testing limits the opportunity for healthcare providers to prescribe effective kidney-protecting medications, such as SGLT2 inhibitors and GLP-1 receptor agonists, which have been shown to improve outcomes when initiated early in the disease process. This gap in care not only affects individual patients but also contributes to a broader public health issue, as CKD is a growing epidemic with significant implications for healthcare systems. Ultimately, the underutilization of albuminuria quantification testing can perpetuate health disparities, particularly among vulnerable populations who may already face barriers to accessing care.

Q: How can primary care providers be better supported and incentivized to follow up on abnormal urine dipstick results, given the competing demands and time constraints they face?

To enhance follow-up on abnormal urine dipstick results, primary care providers can be better supported through a multifaceted approach that addresses both systemic and individual barriers. First, improving the visibility of abnormal results within electronic health records (EHRs) is essential. Implementing color-coded alerts or notifications that highlight abnormal dipstick results can prompt providers to take necessary actions without requiring additional cognitive effort. Additionally, integrating clinical decision support tools within EHR systems can guide providers on the appropriate follow-up actions based on specific test results. These tools can include reminders for albuminuria quantification testing and educational resources about the importance of early CKD management. Incentivizing follow-up through value-based care models can also motivate providers. Financial incentives tied to quality metrics related to CKD screening and management can encourage adherence to guidelines. Furthermore, providing training and resources on time management and prioritization can help primary care providers balance competing demands during patient visits, ensuring that critical follow-up actions are not overlooked.

Q: What innovative approaches, beyond EHR-based interventions, could be explored to improve the accessibility and affordability of newer kidney-protecting medications for patients at risk of or with chronic kidney disease?

Improving the accessibility and affordability of newer kidney-protecting medications requires innovative strategies that address both systemic barriers and individual patient needs. One approach is to establish patient assistance programs in collaboration with pharmaceutical companies, which can help subsidize the cost of medications for low-income patients. These programs can be promoted through community health initiatives to ensure that eligible patients are aware of available resources. Additionally, implementing a tiered pricing model based on income or insurance status could make these medications more affordable for a broader range of patients. This model would require collaboration between healthcare providers, insurers, and pharmaceutical companies to create a sustainable framework that prioritizes patient access. Telehealth services can also play a crucial role in improving access to care. By offering virtual consultations, healthcare providers can reach patients in underserved areas, ensuring they receive timely prescriptions and follow-up care without the barriers of transportation or time constraints. Lastly, community-based education programs can empower patients with knowledge about CKD and the importance of adhering to prescribed treatments. By fostering a supportive environment that encourages medication adherence and self-management, patients may be more likely to seek and maintain access to necessary kidney-protecting therapies.

Core Concepts

Only 1 in 15 patients with proteinuria detected by urine dipstick in primary care undergo follow-up albuminuria quantification testing, despite guidelines recommending this as the next step for accurate diagnosis and treatment of chronic kidney disease.

Abstract

The study by Xu et al. examined real-world data from 1 million primary care patients and found significant gaps in the follow-up of abnormal urine dipstick test results. Key insights:

13% of patients had proteinuria on urine dipstick, but only 6.7% underwent follow-up albuminuria quantification testing within the next year.
Even for higher levels of proteinuria (3+), the follow-up rate was just 8%.
Patients with diabetes had the highest follow-up rate at 16.6%, compared to 3.8% for those without diabetes.
Potential reasons for low follow-up include lack of visibility of abnormal results in electronic health records, primary care providers being overwhelmed by other patient concerns, and uncertainty around who should prescribe newer kidney-protecting medications.
Improving EHR systems to better highlight abnormal dipstick results and integrating clinical decision support tools could help increase follow-up rates.
Addressing barriers to accessing newer kidney-protecting medications, such as high costs, is also crucial to improving care for patients with chronic kidney disease.

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Stats

Only 1 in 15 urine dipstick tests showing proteinuria in the primary care setting are followed up with albuminuria quantification testing.
13% of patients had proteinuria on urine dipstick, but only 6.7% underwent follow-up albuminuria quantification testing within the next year.
Patients with diabetes had the highest follow-up rate at 16.6%, compared to 3.8% for those without diabetes.

Quotes

"Evidence-based prescription of renin–angiotensin system inhibitors, glucagon-like peptide-1 receptor (GLP-1) agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and nonsteroidal mineralocorticoid receptor antagonists (nsMRAs) relies on the level of albuminuria."
"I have patients who cannot fill these medications because the copay is too high...it was over $300 per month."

Key Insights Distilled From

Low Follow-up of Urine Dipstick Tests in Primary Care

by Will at www.medscape.com 10-02-2024

https://www.medscape.com/viewarticle/low-follow-abnormal-urine-proteinuria-dipstick-tests-primary-2024a1000hzn

Low Follow-up of Urine Dipstick Tests in Primary Care

Deeper Inquiries

What are the potential consequences of this widespread underutilization of albuminuria quantification testing on patient outcomes and the management of chronic kidney disease?

The underutilization of albuminuria quantification testing has significant implications for patient outcomes and the overall management of chronic kidney disease (CKD). First and foremost, the failure to follow up on abnormal urine dipstick results can lead to delayed diagnosis and treatment of CKD. Early identification of albuminuria is crucial, as it serves as a key prognostic indicator for kidney function decline and cardiovascular risk. Without timely intervention, patients may progress to more advanced stages of CKD, which are associated with increased morbidity, mortality, and healthcare costs.
Moreover, the lack of follow-up testing limits the opportunity for healthcare providers to prescribe effective kidney-protecting medications, such as SGLT2 inhibitors and GLP-1 receptor agonists, which have been shown to improve outcomes when initiated early in the disease process. This gap in care not only affects individual patients but also contributes to a broader public health issue, as CKD is a growing epidemic with significant implications for healthcare systems. Ultimately, the underutilization of albuminuria quantification testing can perpetuate health disparities, particularly among vulnerable populations who may already face barriers to accessing care.

How can primary care providers be better supported and incentivized to follow up on abnormal urine dipstick results, given the competing demands and time constraints they face?

To enhance follow-up on abnormal urine dipstick results, primary care providers can be better supported through a multifaceted approach that addresses both systemic and individual barriers. First, improving the visibility of abnormal results within electronic health records (EHRs) is essential. Implementing color-coded alerts or notifications that highlight abnormal dipstick results can prompt providers to take necessary actions without requiring additional cognitive effort.
Additionally, integrating clinical decision support tools within EHR systems can guide providers on the appropriate follow-up actions based on specific test results. These tools can include reminders for albuminuria quantification testing and educational resources about the importance of early CKD management.
Incentivizing follow-up through value-based care models can also motivate providers. Financial incentives tied to quality metrics related to CKD screening and management can encourage adherence to guidelines. Furthermore, providing training and resources on time management and prioritization can help primary care providers balance competing demands during patient visits, ensuring that critical follow-up actions are not overlooked.

What innovative approaches, beyond EHR-based interventions, could be explored to improve the accessibility and affordability of newer kidney-protecting medications for patients at risk of or with chronic kidney disease?

Improving the accessibility and affordability of newer kidney-protecting medications requires innovative strategies that address both systemic barriers and individual patient needs. One approach is to establish patient assistance programs in collaboration with pharmaceutical companies, which can help subsidize the cost of medications for low-income patients. These programs can be promoted through community health initiatives to ensure that eligible patients are aware of available resources.
Additionally, implementing a tiered pricing model based on income or insurance status could make these medications more affordable for a broader range of patients. This model would require collaboration between healthcare providers, insurers, and pharmaceutical companies to create a sustainable framework that prioritizes patient access.
Telehealth services can also play a crucial role in improving access to care. By offering virtual consultations, healthcare providers can reach patients in underserved areas, ensuring they receive timely prescriptions and follow-up care without the barriers of transportation or time constraints.
Lastly, community-based education programs can empower patients with knowledge about CKD and the importance of adhering to prescribed treatments. By fostering a supportive environment that encourages medication adherence and self-management, patients may be more likely to seek and maintain access to necessary kidney-protecting therapies.