Uptake of urine protein assessments low for adults with type 2 diabetes, CKD
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Key takeaways:
- Less than half of adults with type 2 diabetes or CKD undergo a urine protein assessment or use ACE inhibitors or angiotensin II receptor blockers.
- Researchers said new strategies needed to reverse these trends.
Adults with type 2 diabetes, chronic kidney disease or both conditions have high rates of hospital admissions and ED visits due in part to a low uptake of medications and a lack of engagement with routine assessments, researchers reported.
In a brief report published in The Journal of Diabetes and Its Complications, Kevin M. Pantalone, DO, ECNU, FACE, director of diabetes initiatives and a staff endocrinologist in the department of endocrinology at the Cleveland Clinic, and colleagues analyzed electronic health record data from adults with CKD, type 2 diabetes or both who were treated in the Cleveland Clinic Health System from 2005 to 2019. The analysis revealed that most people with these conditions did not have a urine protein assessment or use several classes of medications or visit a specialist.
“Simply put, there is a tremendous opportunity to improve the management of patients with CKD, type 2 diabetes and CKD plus type 2 diabetes,” Pantalone told Healio.
Researchers identified 122,276 adults with CKD, 63,643 adults with type 2 diabetes and 35,255 adults with CKD and type 2 diabetes to include in the study. Adults aged 18 years and older with at least one outpatient visit in 2019 and at least two outpatient visits with a primary care, endocrinology, nephrology or cardiology provider before or during 2019 were included.
Most adults in the full cohort did not have a urine protein assessment in 2019. Assessment data were observed in 30.2% of the CKD and type 2 diabetes group, 20.1% of type 2 diabetes group and 7.6% of the CKD group.
Medication utilization was also low among the study population. Use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers was higher in the CKD plus type 2 diabetes group (42.4%) compared with type 2 diabetes group (31.5%) and the CKD group (27.7%). In a sensitivity analysis that only included adults with an estimated glomerular filtration rate of less than 60 mL per minute in 2019, similar rates were observed.
Of the study cohort, 52.9% of those with CKD, 54.9% of adults with CKD and type 2 diabetes, and 41.8% of those type 2 diabetes had at least one hospital admission. The percentage of adults with at least one ED visit was 26.5% with CKD, 28.8% with CKD and type 2 diabetes, and 18.6% with type 2 diabetes. Despite the high rates, less than 10% of adults in all three groups attended a visit with a nephrologist or endocrinologist and less than one-third of each group visited a cardiologist.
Pantalone said multiple strategies need to be implemented to reverse the trends observed in the study.
“Patient empowerment and engagement in their management plans is always very beneficial in helping to close care gaps,” Pantalone said. “In addition, providing education and reinforcing guideline recommendations to the health care providers would also help to move the needle. The key point is that if one does not check the urine protein, one will not know if a patient has proteinuria, and thus, won’t know who requires treatment.
“An additional strategy would be approaching the problem from a population health perspective,” Pantalone said. “We have the means to identify patients within the electronic medical system that should have, but did not, undergo urine protein assessments. Once identified, orders could be placed, and electronic instructions sent to the patient instructing them to provide a urine sample to the lab.”
Pantalone said interventions need to be developed and implemented in future studies to improve urine protein assessment rates and make sure patients are receiving appropriate medication.
For more information:
Kevin M. Pantalone, DO, ECNU, FACE, can be reached at pantak@ccf.org.
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