The Diabetes Staging System (DSS): A Pilot Study Assessing Feasibility, Provider Engagement and Implementation Challenges of a Novel Staging System for Type 2 Diabetes

Moahad S Dar,1,2 Junhong Zhang,3 Anna Ashline,3 Swetha Kota,4 Sandra Woolson,5 Nadya T Majette,1 Hayden B Bosworth6 1Department of Medicine, Greenville VA Healthcare Center, Greenville, NC, USA; 2Department of Internal Medicine, Brody School of Medicine, Greenville, NC, USA; 3Department of Primary Care, Greenville VA Healthcare Center, Greenville, NC, USA; 4Department of Biostatistics, Institute of Medical Research (IMR), Durham, NC, USA; 5Department of Biostatistics, Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at Department of Veteran Affairs, Durham, NC,USA; 6Department of Population Health Science, Duke University, Durham, NC, USACorrespondence: Moahad S Dar, Email [email protected] and Objective: Type 2 diabetes (DM2) currently lacks a standardized staging system that can be used to predict survival and guide providers towards guideline concordant care much like TNM staging does for cancer. We conducted a pilot study to assess the feasibility, provider engagement and implementation challenges of the DSS and examined if guideline concordant care improved especially SGLT2i/GLP-1a use in Veterans DM2 patients with cardiorenal disease.Methods: A 6-month pilot study implemented DSS in VA primary care clinics between December 2023–September 2024. Study visits were at baseline and 6 months. Primary outcome: the initiation of SGLT2i/GLP-1a in Veteran DM2 patients with CVD/CKD compared to baseline. Secondary outcomes: weight, blood pressure, hemoglobin A1C, glomerular filtration rate (GFR), and medication adherence compared to baseline. Inclusion criteria: Male or female Veterans between the ages of 18– 75 years with DM2 and ≥ 1 CV event and/or CKD and not on SGLT2i/GLP-1a. Exclusion criteria: Veterans with contraindications to SGLT2i/GLP-1 and/or a serious mental health disorder.Results: After baseline visit, all providers prescribed to 14/14 patients at least one of the medications with 12/14 prescribed SGLT2i and 2/14 prescribed GLP-1a. We found 13/14 (93%) patients to still be on at least one of the medications at 6 months. At 6 months compared to baseline, weight (216 lbs. ± 41 → 213 lbs. ± 39), blood pressure (141/76 ± 20/10 → 132/73 ± 17/10), A1C (7.7% ± 1.5% → 7.4% ± 0.8%) modestly decreased but GFR remained stable (64 mL/min ± 17 → 64 mL/min ± 19). Medication adherence was continued for all 13 patients (Medication possession ratio was ≥ 80%).Conclusion: DSS use was associated with increased SGLT2i/GLP-1a prescribing by VA primary care providers and medication adherence in Veterans DM2 patients with CVD/CKD. The DSS could help improve cardiorenal outcomes and guideline concordant in their DM2 patients in the future if larger studies can validate these findings.Clinical Trials Registration Number: NCT06142006.Keywords: type 2 diabetes, healthcare delivery, SGLT2i, GLP-1a