Enhancing Kidney Care for People with Diabetes: Tips for DCES in Practice
Andrew Bzowyckyj, PharmD, BCPS, CDCES
The standards of care in diabetes are continually evolving as new science and evidence emerges, which ultimately enhances the overall quality of care for people living with diabetes. Admittedly, this can be a lot to keep up with as a practicing Diabetes Care & Education Specialist (DCES)! Although helping patients achieve their glucose targets is critical for preventing complications, a broader person-centered approach to diabetes care & education rooted in the ADCES7 Self-Care Behaviors™ is essential to help patients truly attain better health over the longer term. This blog post will focus on the “reducing risks” self-care behavior within the ADCES7™, specifically as it relates to kidney care, including practical approaches for the busy DCES to integrate into their practice.1
Kidney health is evaluated using two different measures: the estimated glomerular filtration rate (eGFR) and the urine albumin to creatinine ratio (UACR). Both are essential for getting a full picture of one’s kidney health, and therefore considered a standard of care.
The 2023 ADA Standards of Medical Care in Diabetes recommend all people living with type 1 diabetes for at least 5 years and all people living with type 2 diabetes (regardless of treatment or duration) should have their eGFR and UACR evaluated at least annually. Furthermore, patients with a UACR > 300 and/or an eGFR of <60 mL/min should be monitored more frequently (e.g., twice annually).2
Unfortunately, the percentage of adults in the US at high risk for CKD (including people living with diabetes) who have both tests routinely measured is alarmingly low. In a 2021 retrospective analysis of a nationwide commercial laboratory database, the rate of patients with diabetes and/or hypertension having both tests completed each year was:3
· 28.7% for people with diabetes
o 83.6% of people in this subgroup had at least one eGFR measurement
o 32.2% of people in this subgroup had at least one UACR measurement
· 10.5% for people with hypertension
· 41.4% for people with both diabetes and hypertension
Other analyses completed in primary care settings identified similar findings - approximately 50% of people living with type 2 diabetes do not receive this basic standard of care, contributing to barriers of slowing CKD progression before complications develop.4,5
The DCES Solution:
Although this is a nationwide problem, many of the solutions start at the local level. Therefore, here are some potential strategies for any DCES to consider leveraging in their own practice:
· DSMES curriculum: Dedicate time within your curriculum to discuss BOTH lab parameters, including what each is evaluating and why both are essential for getting the full picture of your kidney health. Just like how you wouldn’t advise someone to get an A1C without explaining what that is, consider the same approach for the eGFR & UACR.
o Here is a helpful patient education resource on the CKD Heat Map from the National Kidney Foundation in case you are in need for updated materials to help patients understand this topic.6
· Initial DSMES patient assessment: Incorporate patients’ kidney health measures into your intake forms and the conversation during your initial DSMES assessment. Most DCES are likely familiar with the “ABCs of diabetes” (i.e., A1C, blood pressure, cholesterol), but why stop there?! Although it ruins the mnemonic, adding the eGFR and UACR to that list will be worth it to help ensure your patients are more knowledgeable about their kidney health.
· Normalize the lingo: Ask patients about their eGFR & UACR (e.g., their “kidney numbers”). If they don’t know one or both, ask about their familiarity with these measures, and if education is warranted, ask permission to explain their importance. Although we must never shame patients for not knowing the answer, there are tactful ways to ask patients this question that emphasize the importance of being familiar with these numbers without ridiculing or shaming, similar to how you might treat an A1C.
· Order these tests directly: Depending on how your scope is defined or practice is set up, you may be able to address this gap by directly ordering these tests under a protocol or standing order. Many DSMES programs authorize nurses, dietitians, pharmacists, and/or other staff to enter orders for a patient to measure their A1C. If this describes your situation, work with your institution and collaborating prescribers to see if the eGFR and UACR can be treated the same way! Both measures are clearly supported by the ADA Standards of Medical Care in Diabetes and included within different quality reporting systems including the NCQA HEDIS measures and the CMS Merit-based Incentive Payment System (MIPS) program.7,8 Specifically, the Kidney Health Evaluation for Patients with Diabetes (KED) is measured as the percent of patients 18-85 years of age (18-75 for MIPS) with diabetes who had an eGFR AND UACR measured within the reporting year. This means a provider’s or practice’s performance on this quality measure can directly affect their reimbursement rate from government and other payers. Money is quite literally on the line here – and the DCES is in the perfect position to assist!
· Help the patient prepare for the test: From my personal experience, one of the biggest barriers for patients getting the UACR test completed is being ready to provide a urine sample when they’re at the lab. Most patients are used to getting bloodwork, but don’t always know a urine sample will also be required. Therefore, educate patients in advance to be ready to provide a urine sample at their lab appointment in order to get everything done in one visit (and perhaps even one copay depending on their insurance).
· Address potential misconceptions: Lastly, I do not know if others have experienced this too, but I’ve encountered patients who have expressed concerns that their urine sample may be used for other purposes beyond measuring their UACR (e.g., urine drug screen). Therefore, having a conversation with patients that these tests are only measuring what is requested in the order (and assuring the patient that the UACR was the order that was entered) may provide some assurances and reduce any stigma the patient may be experiencing.
Sometimes the best place to start addressing a practice gap is to see how real it is for you in your setting. Therefore, start with your practice!
· What percentage of patients enrolled in your DSMES program or listed on your patient panel have had an eGFR and UACR measured in the past year?
· Are you fully leveraging your role and scope by requesting the authorization to order these labs, thereby improving your practice’s screening rates and patients’ awareness of kidney disease?
· Do your handouts and educational materials feature eGFR and UACR as prominently as the ABCs (i.e., A1C, blood pressure, cholesterol)?
· How often are you asking patients about their kidney numbers?
Like most chronic conditions, CKD is best treated when caught early, ideally before it even begins. Help the patients you serve achieve better health by reminding them to check on their kidneys!
What other tips do you have for helping people with diabetes get their recommended screenings for kidney health?
1. Association of Diabetes Care & Education Specialists. An effective model of diabetes care and education: the ADCES7 Self-Care Behaviors™. Sci Diabetes Self-Manag Care. 2021;47(1):30-53. Accessed February 21, 2023.
2. American Diabetes Association. Chronic kidney disease and risk management: Standards of Care in Diabetes - 2023. Diabetes Care. 2023;46(Suppl. 1):S191-S202.
3. Alfego D, Ennis J, Gillespie B, et al. Chronic kidney disease testing among at-risk adults in the US remains low: real-world evidence from a national laboratory database. Diabetes Care. 2021;44(9):2025-2032.
4. Stempniewicz N, Vassalotti JA, Cuddeback JK, et al. Chronic kidney disease testing among primary care patients with type 2 diabetes across 24 US health care organizations. Diabetes Care. 2021;44(9):2000-2009.
5. Szczech LA, Stewart RC, Su HL, et al. Primary care detection of chronic kidney disease in adults with type 2 diabetes: the ADD-CKD Study (awareness, detection, and drug therapy in type 2 diabetes and chronic kidney disease). PLoS One. 2014;9(11):e110535.
6. National Kidney Foundation. Kidney numbers and the CKD Heat Map. Accessed Feburary 21, 2023. https://www.kidney.org/sites/default/files/kidney-numbers_ckd-heatmap.pdf
7. National Committee for Quality Assurance. HEDIS MY 2023 Measure Descriptions. Accessed February 21, 2023. https://www.ncqa.org/wp-content/uploads/2022/07/HEDIS-MY-2023-Measure-Description.pdf
Electronic Clinical Quality Improvement Resource Center. Kidney Health Evaluation. Accessed February 21, 2023. https://ecqi.healthit.gov/ecqm/ec/2023/cms951v1