Cases in High Value Care

Usefulness of urine protein dipstick testing as part of routine prenatal care. 

Alicia Firestone, MS3 & Bailey Wooten, MS3
Mentor: Lauren D. Demosthenes, MD
3/10/17

Clinical Scenario A: A healthy 30 y/o G2P1001 at 22 weeks presents for her monthly prenatal visit. Her pregnancy has been uncomplicated.  She is escorted to the restroom and given a urine specimen cup. Unable to void, she asks the purpose of collecting a urine sample. The nurse explains that pregnant women may have protein in their urine during pregnancy, and this along with hypertension is known as preeclampsia. In the exam room the nurse takes her vital signs.  Her blood pressure is 110/75.  During her visit she denies headaches, vision changes, epigastric pain, polyuria or edema in her lower extremities.  Her fundal height is 23 cm.  The nurse knocks on the door during the exam to deliver a glass of water to the patient, in hopes that she will be able to void. The patient waits in the exam room after seeing her provider for 15 minutes until she is able to provide a urine sample. The nurse puts on a pair of gloves, retrieves the specimen cup from the shelf in the restroom, and brings it to the lab. She walks to the lab and dips the protein dipstick in the specimen cup, which reads negative. The nurse discards the specimen cup in a bin. At the end of the day she will pour out the urine in each specimen cup and take the biohazard bag with the empty cups to the disposal room. 

Healthcare burden Scenario A:Patient Experience: With Patient A’s prenatal visit running 15 minutes over, she left the office in a hurry to pick up her kids from school on time. She is now newly concerned about her potential to have a positive urine protein dipstick at her next appointment, despite being asymptomatic and having no associated risk factors for preeclampsia. RN Experience: After a busy day running around the office, Nurse A would like to get home to her family and make dinner. Before she can leave, she must take the time to collect all the dirty urine cups and dispose of them.

Clinical Scenario B: A healthy 30 y/o G2P1001 at 22 weeks presents for her monthly prenatal visit. Her pregnancy has been uncomplicated.  The nurse escorts the patient from the waiting room to the exam room. She obtains vital signs on the patient and her blood pressure is 110/75. During the encounter with her provider, the patient denies headaches, vision changes, epigastric pain, polyuria or edema in her lower extremities. As a result, it is decided that a urine protein dipstick is unnecessary at this visit.  The patient is escorted out and makes her follow up appointment at the front desk.

Healthcare burden Scenario B: Patient Experience: With Patient B’s prenatal visit running as scheduled, she was able to make it on time to pick up her kids from school without having to rush. She is not worried about possibly having a positive urine protein dipstick at her next appointment because she has had no problems with her blood pressure and no clinical signs or symptoms of preeclampsia. RN Experience: After a busy day running around the office, Nurse B is able to grab her belongings and head home to her family for the night. There are no remaining tasks left, such as emptying and discarding a day’s worth of urine samples. She is so thankful that her place of employment has streamlined their preeclampsia protocols.

Discussion questions:

  1. What is the clinical utility of the urine dipstick test in pregnant women?
  2. Would eliminating the urine dipstick test in low risk pregnancies lead to increased patient satisfaction, decreased time spent per patient for nursing staff, and improved health care value?

Teaching Moment: The utility of urine dipstick testing in pregnant women has been debated for years, with studies suggesting minimal use in asymptomatic patients. In the absence of both risk factors and symptoms for preeclampsia, there has not been shown to be a benefit in routine urine dipstick testing for women of low risk.1 The USPSTF Task Force recently updated their screening recommendations in support of this position, stating that adequate evidence has been found against screening for preeclampsia with point of care urine dipsticks in asymptomatic patients, as this has been shown to have low diagnostic accuracy for detecting proteinuria.2 Both the USPSTF and ACOG recommend that the best laboratory studies to confirm a diagnosis of preeclampsia are a 24 hour urine collection or P:C ratio, and enforce that routine screening for preeclampsia including a urine dip for protein in low risk women is not recommended.3 An example of a better indication for urine dipstick testing would be if patient A had presented to the office with a blood pressure of 145/88 upon check in. It would now be reasonable to perform a point of care urine dipstick test in office, followed up by a urine P:C ratio or a 24 hour collection to confirm the diagnosis.

Intervention and Result: Health care value can be defined as the sum of quality care plus patient experience, divided by total cost.  With this in mind, the greatest improvements in value are made by increasing not only quality of care, but also the overall patient satisfaction and experience. Eliminating routine urine dipstick testing can be considered an effort to improve health care value by increasing both factors of quality and patient experience.  Improvement in quality is demonstrated by the fact that urine dipstick testing is not considered standard of care by ACOG or the USPSTF, while improvement in patient experience is exemplified above in scenario A. To further address patient experience, one may consider taking a closer look at the schedule for routine prenatal visits. ACOG recommends that women have monthly prenatal visits up to 28 weeks, then visits every two weeks from 28-36 weeks, and weekly visits thereafter. Most institutions that still collect urine dipsticks will start doing so early in prenatal care. This testing is both unnecessary and time consuming, and the high false positive rate may lead to added stress on the patient that could be reasonably avoided. Healthcare staff would also benefit form eliminating routine urine dipstick testing as nurses spend a notable amount of time throughout the day administering specimen cups, collecting urine samples, screening for protein, and disposing of wastes.

The CenteringPregnancy program and our health system’s midwifery practice are examples of low risk patient populations that do not perform urine dipstick tests as a part of routine prenatal care for preeclampsia screening.4 To change the culture throughout Greenville Health System, we will need to educate providers about this recommendation and analyze whether changing practice can enhance office efficiency and patient satisfaction. We also plan to evaluate downstream testing that is done on the routine dipstick. 

References:

  1. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 7th ed. (2012): 109-110, 192-194. Web. 24 Jan. 2017.
  2. US Preventive Services Task Force. "USPSTF Recommendation: Screening for Preeclampsia." JAMA 317.16 (2017): 1661-1667 Web. 01 May 2017.
  3. American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. “Hypertension in Pregnancy.” (2013). Web. 10 Jan. 2017.
  4. Picklesimer, Amy H. and Billings, Deborah et al. "The Effect of Centering-Pregnancy Group Prenatal Care on Preterm Birth in a Low-Income Population." Obstetrical & Gynecological Survey 67.9 (2012): 525-26. Web. 25 Feb. 2017
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