Optimizing SGLT2 inhibitor and GLP-1 RA prescribing in high-risk patients with diabetes: a Department of Veterans Affairs quality improvement intervention.

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium glucose cotransporter-2 (SGLT2) inhibitors have dramatic clinical benefits, but many appropriate patients do not receive them. We developed a quality improvement (QI) intervention to increase the adoption of these drugs in patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and/or heart failure (HF). The purpose of this study was to examine whether the intervention increased the use of SGLT2 inhibitors and GLP-1 RAs.

METHODS

The intervention included: (1) education, academic detailing (1:1 pharmacist to clinician coaching), and audit and feedback directed at providers and allied health professionals at the Veterans Affairs Ann Arbor Healthcare System (VAAAHS); (2) outreach and inreach to patients with T2D and ASCVD, CKD, and/or HF who were not on GLP-1 RAs or SGLT2 inhibitors at baseline. Patients were identified and outcomes evaluated using existing VA national reports. We performed a difference-in-difference analysis of the change in GLP-1 RA and SGLT2 inhibitor prescribing rates before, during, and after the intervention, comparing rates in VAAAHS to rates in the same VA region (called a Veterans Integrated Service Network (VISN)) and the VA nationally to determine whether the rates of prescribing increased faster in VAAAHS than the VISN or VA nationally.

RESULTS

Home telehealth nurses and clinical pharmacy practitioners (CPPs) provided outreach to 445 patients; 48% (n = 215) of whom initiated SGLT2 inhibitors or GLP-1 RAs. Four CPPs provided 101 academic detailing sessions to 72 providers. Prior to the intervention, the prescribing rate was 22.7% in VAAAHS, 20.3% in the VISN 10 region, and 18.7% in VA nationally. At the end of the 12-month intervention, the prescribing rate had increased to 37.9% in VAAAHS, 28.4% in the VISN 10 region, and 26.5% in VA nationally. Six-months post-intervention, the prescribing rate continued to increase to 42.4% in VAAAHS, 32.2% in the VISN 10 region, and 30.2% in VA nationally. The rate of prescribing growth in VAAAHS was significantly faster than in the VISN or VA nationally (p < 0.001).

CONCLUSION

Our multidisciplinary QI intervention increased SGLT2 inhibitor and GLP-1 RA prescribing approximately 8% points faster than the national average.