Diabetic kidney disease (DKD) is the leading cause of end-stage renal-disease in New Zealand. Approximately half of people in New Zealand receiving dialysis
have diabetes as the cause of their kidney disease. DKD develops in approximately 30% of people with type 1 diabetes and 40% of people with type 2 diabetes.
A multifactorial approach is recommended to preserve renal function, prevent renal complications and reduce cardiovascular
risk in all patients with diabetes, including those with established DKD. The most important factors in preserving renal
function in people with diabetes are:
- Regular monitoring of renal function
- Optimising glycaemic control
- Managing blood pressure
Patients with diabetes should have their renal function tested at least once a year as part of
their annual diabetes review. Renal testing should include both:
- An albumin:creatinine ratio (ACR), from a first void urine sample if possible
- An estimated glomerular filtration rate (eGFR), which will be automatically generated when a serum creatinine is requested
More frequent testing, e.g. six-monthly, may be appropriate for people with multiple risk factors for DKD, e.g. Māori
ethnicity, frequent use of NSAIDs and hypertension.
Māori and Pacific peoples with DKD often have more severe disease. Māori and Pacific peoples are more likely to have
kidney disease with moderately to severely increased albuminuria than people of European ethnicity. People of Pacific
ethnicity have a 12-fold higher, and Māori six-fold higher, rate of starting treatment for end-stage renal disease than
people of European ethnicity. Among people starting dialysis, diabetes is the underlying cause of renal failure in 74%
of patients of Pacific ethnicity, compared to 68% of Māori and 24% of Europeans.
Further information is available from: “Slowing progression of renal dysfunction in patients with diabetes”
Summary
This audit identifies patients with type 1 and type 2 diabetes and records the frequency and type of renal monitoring that they are receiving.
As an optional extra, the ethnicity of patients can also be recorded to determine if there are disparities in renal monitoring.
Audit standards
Ideally, all patients with diabetes will have their renal function tested at least once a year. Testing should include both a urinary ACR and serum creatinine from which an eGFR is generated.
Eligible patients
All patients aged over 20 years with diabetes are eligible for inclusion in this audit. This cut-off was chosen because people with type 1
diabetes who are younger are less likely to be monitored in primary care and type 2 diabetes is uncommon in people aged under 20 years.
Identifying patients
You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to identify patients by running a
“query” through their PMS. The patient’s notes are then reviewed to determine if an ACR and eGFR result has been recorded in the previous 12 months.
Sample size
A random sample size of 30 patients with diabetes is likely to be sufficient for the first stage of this audit. It is likely that the
size of the sample will need to be increased if the option of analysing the ethnicity of patients is chosen, depending on the ethnic composition of the practice population.
Criteria for a positive outcome
A positive result is if a patient aged over 20 years with diabetes years has a documented result for an ACR and eGFR in their notes in the past 12 months.
Data analysis
Record whether each patient has had an ACR and an eGFR result entered in their notes in the previous 12 months. If a patient has not had an ACR and eGFR result
entered in their notes during this time they should be flagged for review. After 30 records have been examined record the total number of patients that have a “Yes”
in both the ACR and eGFR column. By dividing the number of patients with a “Yes” in both columns, i.e. ACR and eGFR, by the total number of patients, i.e. 30, the
ratio of patients with diabetes who are receiving appropriate renal monitoring can be determined.
An optional extra is provided in this audit that allows practices to determine if there are ethnic disparities in the renal monitoring of people with diabetes.
This is likely to require the size of the sample to be increased beyond 30 patients to enable meaningful comparisons. In a practice with a high proportion of
Māori and Pacific patients a sample of 50 patients may be sufficient, however, others may need to sample all their patients with diabetes.
On the second data sheet, record whether both an ACR and
eGFR test result has been entered in the patient’s notes in the previous 12 months and record the ethnicity of
each patient. In the bottom half of the data sheet, record the total number of patients for each ethnicity with both an ACR and eGFR result in the previous 12 months
(AG) and record the total number of patients for each ethnicity (E). By dividing AG by E for each ethnicity the ratio of appropriate renal monitoring for each
group can be determined. The monitoring ratios for each ethnicity can then be compared to see if there are ethnic disparities in renal monitoring for people with diabetes.
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
Taking action
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
Effective interventions
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
and behaviour
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
Audit
of Medical Practice summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices
complete the remainder of the Audit of Medical
Practice summary sheet.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.
