Expanding Use of Sodium-Glucose Cotransporter-2 Inhibitor (SGLT2i) In Managing Patients with Diabetes and Chronic Kidney Disease in Primary Care

Abstract

Practice Problem: In 2022, the addendum of standards of medical care in diabetes management was annotated to recommend the broader use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) to treat patients with Type 2 diabetes mellitus (DM) and diabetic nephropathy. Despite the Department of Veterans Affairs’ (VA) efforts to include SLGT2i as a formulary, non-restrictive prescription in the primary care ordering menu, the overall utilization rates of SGLT2i remained relatively low in primary care. PICOT: The PICOT question that guided this project was: In patients with DM and chronic kidney disease (CKD) (P), how does an evidence-based guideline algorithm bundle (I) compared to standard care (C) affect providers’ adherence and prescribing practices of including SGLT2 inhibitors (O) within 10 weeks (T)? Evidence: An extensive evidence literature review supported that the algorithm approach with current guidelines has allowed clinicians to identify patients eligible for SGLT2i was based on comprehensive risk assessment with various comorbidities and risk factors. The guideline-based algorithm was a quick reference guide to provide clarity and indication for patients with the most significant potential benefits from SGLT2i therapy. Intervention: The algorithm bundle, designed to reflect the current guidelines, was intended to enhance primary care clinicians' prescribing confidence in SGLT2i and guide better decision-making. The algorithm bundle comprised the physical laminated algorithm card, embedded reminder in the e-prescribing menu, and a focused education session for the primary care providers. Outcome: The project outcomes reflected that the algorithm bundle has clinical significance in improving prescribers’ knowledge of SGLT2i agents and practice compliance, as evidenced by a rise in SGLT2i prescriptions. Conclusion: The algorithm bundle intervention in this project resonates with the American Diabetic Association’s (2022) latest recommendation to widen indications for using SGLT2 to optimize the management of DM and CKD patients. The evidence supports using a guideline-based algorithm to guide clinicians with a comprehensive assessment of high-risk patients and a better decision-making tool. Continued efforts to educate and audit primary care providers are essential to identify potential knowledge gaps and to sustain practice compliance of using SGLT2i as part of the standard of care.