Purpose:
Type 2 diabetes mellitus (T2DM) is a global health issue with substantial costs. To improve care, Ralph H. Johnson VA Health Care System (RHJ VAHCS) adopted the “Potential SGLT2 Candidate by Appointment Dashboard”, a population management tool (PMT). This tool helps providers identify scheduled T2DM patients who are ideal candidates for SGLT2 inhibitors, specifically those with additional risks like kidney or heart disease. The PMT aims to increase prescriptions of SGLT2 inhibitors by proactively alerting providers to upcoming patient appointments. The purpose of this project is to increase appropriate prescribing of SGLT2 inhibitors in the primary care setting.
Methods:
The pre-PMT implementation period is 10/1/2023 - 12/31/2024 followed by the PMT implementation period of 1/1/2025 - 3/31/2026. All primary care providers (PCPs) at RHJ VAHCS were formally introduced to the PMT in August of 2025. Through the months of August-November, hands-on experience was gained through pulling patients with upcoming appointments from a community-based outpatient clinic (CBOC). 51 patients that populated on the PMT were reviewed and those that were determined to be candidates were contacted to initiate SGLT2 inhibitors. Once hands-on experience was complete, smaller meetings were conducted individually at 5 outpatient clinics through November and January to further educate about the PMT. Survey questions were provided to assess providers’ overall comfortability with utilizing the PMT and to determine how many providers planned to implement this PMT in practice. During February and March, weekly meetings were held individually with 8 providers. The Plan-Do-Study-Act model was implemented through the meetings to establish overall facilitators and barriers to utilization of the PMT with the overarching goal to increase utilization for all providers. The primary endpoint of the study is to evaluate the impact of implementation of a PMT on the number of new SGLT2 inhibitor prescriptions initiated by PCPs. Subgroup analysis were included to assess how providers’ subscription to PMT, patients physically viewed on the PMT, and PharmD education on the PMT impacted the rate of new SGLT2 inhibitor prescriptions. The secondary endpoint is to determine the facilitators and barriers to implementation of the PMT.
Results
During the pre-PMT implementation period, there was a total of 2,950 new start SGLT2 inhibitor prescriptions at the RHJ facility compared to the PMT implementation period with a total of 2,881 new starts. Of the 2,881 prescriptions, 448 new starts are specific to an associated visit on the PMT which was defined as prescriptions issued within three days of an appointment flagged on the tool. A total of 43,399 total candidates populated on the tool with 448 resulting in new start prescriptions making the overall rate of new starts with PMT utilization 1.03%. The rate of new starts increases up to 2.47% when compared to providers subscriptions to the PMT and increases to 4.51% when compared to patients reviewed on the PMT. When comparing any type PMT interaction including both subscriptions and views, that rate of new starts with subscriptions and views is 3.88%, subscription with no views is 1.89%, and no subscription with views 7.02%. When looking at pre/post PharmD education on the PMT, the rate of new starts decreased from 3.53% to 2.44% with a p-value of 0.0194 (significance ≤ 0.01). For the secondary endpoint, common facilitators to use include sustainability (6%, n=1), ease of use (17%, n=3), data accuracy (18%, n=3), timeliness (18%, n=3), and clinical relevance (41%, n=7). The common barriers to use include change fatigue (13%, n=5), information overload (15%, n=6), perceived lack of value (13%, n=5), usability (8%, n=3), lack of training or technical support (2%, n=1), workflow disruption (23%, n=9), data quality concerns (8%, n=3), and time constraints (18%, n=7).
Conclusion:
In conclusion, most providers feel that it is a priority to initiate SGLT2 inhibitor prescriptions for the cardiorenal protective properties. While the overall number of new start SGLT2 inhibitors remains relatively the same after the PMT was implemented, the PMT demonstrated having a positive impact on the rate of new start SGLT2 inhibitor prescriptions through subscribing and viewing patients with the tool. Time constraints, workflow disruption, and alert fatigue were common barriers to utilization of the PMT. While the “Potential SGLT2 Candidate by Appointment Dashboard” is a population management tool that aims to increase appropriate prescribing of SGLT2 inhibitors, updates that incorporate changes recommended by providers may lead to an uptake of utilization in the future.
