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

Abstract

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.