Optimizing utilization of SGLT2 inhibitors in patients with type 2 diabetes mellitus and chronic kidney disease in a VA primary care clinic: An interdisciplinary quality improvement project

Abstract: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce the progression of chronic kidney disease (CKD) to end-stage renal disease, doubling of creatinine, and death from renal causes in patients with type 2 diabetes mellitus (T2DM) and CKD.1-3 In 2020, the Kidney Disease: Improving Global Outcomes Diabetes Work Group released a clinical practice guideline 4 with a strong (Grade 1A) recommendation for utilizing SGLT2i to treat patients with T2DM and CKD with eGFR >= 30 mL/min per 1.73 m2. Despite this, SGLT2i remained under-prescribed in the Iowa City VA resident primary care clinic, with only 51% of eligible patients having prescriptions for SGLT2i in May of 2022. The Institute for Health care Improvement's Model for Improvement 5 was used to design this quality improvement project and the team aimed for a 20% relative increase of SGLT2i prescriptions in patients with T2DM and CKD over a 5-month period. The interdisciplinary team consisted of internal medicine residents, pharmacists, and physician faculty mentors. Based on interviews with key stakeholders, barriers to SGLT2i prescribing included lack of familiarity with recent Kidney Disease: Improving Global Outcomes guidelines, lack of knowledge about indications and contraindications for SGLT2i, and uncertainty about how to counsel patients before prescribing. The CKD Report, a preexisting, automatically generated dataset found within the VA Primary Care Almanac, was used to identify patients who met the criteria of (1) hemoglobin A1c (HbA1c) of 6.5% to 10.0%, (2) use of at least 1 medication for diabetes, (3) eGFR of 45-90 mL/min per 1.73 m2, and (4) no active prescription for an SGLT2i. Patients who met the initial screening criteria with the CKD Report were then manually reviewed for eligibility and exclusion. Patients were excluded if they had risk factors for, or a history of recurrent urinary tract infections, pancreatitis, lower extremity amputation or nonhealing ulcers, history of type 1 DM, or prior trial and intolerance of SGLT2i. A standardized note was placed in the electronic medical record before eligible patients' primary care appointments, with their provider cosigned. The note alerted the provider of the patient's SGLT2i eligibility and contained information on SGLT2i benefits, indications, contraindications, and potential side effects. The University of Iowa Institutional Review Board determined that this project did not meet the regulatory definition of human subjects research. Across 2826 patients within the Iowa City VA resident primary care clinic, the team identified 365 patients with T2DM and CKD. After review, 57 patients were excluded according to the criteria identified above, and 157 patients were already prescribed an SGLT2 inhibitor. Of the 151 patients who met inclusion criteria, 68 patients did not have an upcoming appointment within the 5-month intervention period. Of the 83 patients who had a note placed by the team pharmacist, at the conclusion of the intervention period, 18 of these patients received a new prescription for an SGLT2i. This resulted in an 11.5% relative increase and a 5.8% absolute increase in prescriptions. This project demonstrated that an interdisciplinary, note-based intervention increased prescriptions of SGLT2i within this VA primary care clinic. The project did not meet the aim of a 20% relative increase. A significant proportion of patients (40/83) had providers defer SGLT2i initiation because their HbA1c was at or below goal. A major lesson of this project was recognizing that the Primary Care Almanac and CKD Report are universally available tools within the VA system and demonstrate value for data acquisition and patient eligibility screening. Limitations of this project include the 5-month intervention period and the requirement of manual effort to extract data, review charts, and place notes. Potential next steps include adapting the note to highlight the benefits of SGLT2i even when HbA1c is at goal, and applying this method to other novel medications that may have similar barriers to prescription.

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