Outcomes of Automatic E-Consults in the Use of SGLT2 Inhibitors and GLP-1 Receptor Agonists in Rural Veterans with CKD

Background: Sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) are recommended in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D), however recent analyses have revealed underutilization of these agents in clinical practice. Management of T2D and CKD can be complex, and often the burden is placed on the primary care provider (PCP). Automatic e-consults can be of great benefit in rural areas, where access to in-person specialty appointments is limited.In this pilot study, we initiated an automatic e-consult program at a single Veterans Affairs (VA) Health System, targeting veterans with CKD and T2D who were not on guideline-directed medical therapy, and evaluated actions taken by veterans’ PCP. Methods: Using data from VA Corporate Data Warehouse, we identified rural veterans with CKD and T2D who were not on guideline-directed medical therapy. We chose 100 veterans, reviewed the chart and completed an automatic e-consult that was sent to the veteran’s PCP. One month post e-consult, we reviewed the chart again to evaluate provider actions. Results: Mean age was 80.0 ± 6.3 years with 5% female, 0% African Americans and 2% Hispanic/Latino. Nurse practitioners were the assigned PCP for 43 patients, physicians for 31 patients and physician assistants for 26 patients. Provider actions were triggered in 31% of cases; 10% filled a new prescription, 11% offered patient a new prescription but patient refused and 10% noted plans to discuss at their next visit with the patient. Physician assistants were the most likely to act on the recommendations (39%), followed by physicians (32%) and nurse practitioners (26%). Conclusion: Automatic e-consults in rural veterans with T2D and CKD triggered a provider action a third of veterans. Further research elucidating provider causes for discrepancy in guideline directed medical therapy and real-world implementation is warranted. Funding: Veterans Affairs Support