Pharmacist Outreach and SGLT2 Inhibitor Uptake in Patients With Diabetes and Chronic Kidney Disease

Importance Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to improve clinical outcomes for patients with type 2 diabetes and chronic kidney disease (CKD), yet their uptake in clinical practice remains low. Objective To assess whether pharmacist-led outreach would be associated with increased initiation of SGLT2 inhibitor use among patients with type 2 diabetes and CKD. Design, Setting, and Participants In this quality improvement study, eligible patients identified through an established Veterans Affairs (VA) diabetes dashboard were divided into 2 groups based on the last digit of their Social Security number, creating a pseudorandomized treatment assignment. The study was conducted from February 2022 through April 2024 in 8 VA health systems in the midwestern US. Veterans with CKD (estimated glomerular filtration rate ≥25 and <60 mL/min/1.73 m 2 ) and type 2 diabetes were included. Patients were excluded if they were already prescribed an SGLT2 inhibitor or had an SGLT2 inhibitor allergy, type 1 diabetes, or contraindicating conditions. Intervention Eligible patients in the intervention group were mailed a letter describing the benefits of SGLT2 inhibitors. Patients were then scheduled for a 30-minute telephone visit with a pharmacist. Patients determined to be a candidate for the medication were prescribed empagliflozin. The usual care group received no targeted outreach but could be prescribed the medication during the natural course of care. Main Outcomes and Measures The primary outcome was initiation of an SGLT2 inhibitor, determined by prescription fill, at any point during the study. The secondary outcome was SGLT2 inhibitor prescription fill at 12 months. The exploratory outcomes, assessed by win ratio analysis, included a composite of time to all-cause mortality, kidney failure, heart failure, myocardial infarction, and stroke along with each of these outcomes individually. Longer time to event for the intervention than the control group was considered a win. Results Of 8658 eligible patients (mean [SD] age, 78.7 [8.1] years; 8368 [96.7%] male; 76 [0.9%] American Indian or Alaska Native, 11 [0.1%] Asian, 327 [3.8%] Black, 44 [0.5%] Pacific Islander, 7435 [85.9%] White, and 765 [8.8%] with unknown or unreported race), 4400 (50.8%) were assigned to the pharmacist intervention and 4258 (49.2%) to usual care. The cumulative proportion of SGLT2 inhibitor prescriptions filled 1 year after group assignment was 1476 (33.5%) for the intervention group compared with 659 (15.5%) for control. At 12 months, 864 intervention patients (19.6%) filled a prescription for an SGLT2 inhibitor compared with 415 (9.7%) in the control group. The hazard ratio for initiation of an SGLT2 inhibitor in the intervention vs control group was 1.91 (95% CI, 1.69-2.16; P < .001). No significant difference was observed in the composite clinical outcome (win ratio, 1.02; 95% CI, 0.97-1.07; P = .54). Conclusions and Relevance In this quality improvement study, pharmacist-led outreach was associated with increased initiation of SGLT2 inhibitors; however, limited intervention reach may have constrained the overall impact. Strategies to improve uptake are needed to enhance impact and inform broader SGLT2 inhibitor implementation in patients with CKD and type 2 diabetes.