Sustained Improvement in Urine Testing Quality Indicator Through an Audit‐and‐Feedback Intervention in Japanese Primary Care: A Before‐and‐After Study
Hiromitsu Yamashita, Hayato Takahashi, Masayoshi ShiotaABSTRACT
Background
Annual urine testing using the urine albumin‐to‐creatinine ratio (UACR) or urine protein‐to‐creatinine ratio (UPCR) is recommended for diabetic kidney disease (DKD) screening, yet attainment in nonspecialist primary care in Japan remains approximately 20%, and evidence on whether audit‐and‐feedback can produce sustained improvement in this quality indicator (QI) is limited. We evaluated the impact of an audit‐and‐feedback intervention on urine testing QI attainment and its sustainability after active feedback ceased.
Method
We conducted a single‐center before‐and‐after study at an urban primary care clinic in Tokyo. QI attainment was measured across ten rolling 12‐month windows. Three individualized feedback sessions delivered in 2024 each included physician‐level attainment rates and appointment‐based patient identification lists. Run chart analysis assessed process change, and a post‐intervention physician survey examined facilitators and barriers using the COM‐B framework.
Results
The pre‐intervention median attainment was 18.6%. Following the intervention, attainment rose from 19.7% to 53.7%, an increase of 34.0 percentage points, and the shift rule was satisfied, with eight consecutive points (M3–M10) exceeding the pre‐intervention median. At M9–M10, outside the active intervention period, attainment was 56.5% (36.8 percentage points above baseline). Within‐physician analysis confirmed sustained improvement (Wilcoxon W = 7, p = 0.005; n = 13). The survey identified patient identification lists as the key facilitator, with carry‐forward electronic medical record ordering and uncertainty about post‐test management as primary barriers.
Conclusions
An audit‐and‐feedback intervention achieved substantial and sustained improvement in urine testing QI attainment in nonspecialist primary care. Patient identification lists may have facilitated initial improvement, while sustained attainment may reflect behavioral routinisation.