Key Points:
- Despite demonstrated effectiveness of many SGLT2-inhibitors and GLP-1 agonists at improving both cardiovascular (CV) and kidney outcomes, utilization of these therapies remains low.
- Study investigators performed a randomized remote implementation study among 200 patients at high CV or kidney risk who were eligible for but not prescribed SGLT2-inhibitors or GLP-1 agonists.
- Patients were randomized to either simultaneous education and medication titration or an “education-first” approach with 2 months of education followed by medication titration with primary outcome of guideline-directed medical therapy (GDMT) prescription in 6 months
- A higher proportion of patients in the simultaneous arm versus the education-first arm (70% vs 56%; p<0.001) demonstrated primary outcome at 6 months, suggesting a remote-team based approach with simultaneous education and prescription can improve T2DM GDMT in high CV or kidney risk groups.
Many SGLT2-inhibitors and GLP-1 agonists have demonstrated reduction in CV events as well as improved kidney outcomes in patients with type 2 diabetes mellitus (T2DM), leading to their incorporation into multiple guidelines recommending their use. However, these medications are often under-utilized, at rates less than 20% in some analyses. Though there are many multifactorial barriers to increasing their use, one possible solution is the use of remote care management. Advantages to this approach include its scalability, cost-effectiveness, and natural augmentation with technology, theoretically making both patient communication and medication management easier. In this study, the investigators sought to compare a team-based remote simultaneous education and medication management approach with an education-first followed by medication management thereafter to compare rates of T2DM GDMT prescription.
The study randomized 200 adults with T2DM with elevated CV or kidney risk (as evidenced by HF, CKD, or known or elevated risk of ASCVD). Participants were either allocated to the “simultaneous” arm, which had both diabetes education and start of an SGLT2-inhibitor or GLP-1 agonist over six months, versus the “education-first” arm, which started with two months of diabetes education followed by four months of medication initiation and titration. Primary outcome was prescriptions of either medication at six months, and secondary outcomes included A1c and weight change.
Both arms of the study were balanced with mean age 67 years old, 37% female patients, 22% non-White patients, and mean A1c 7.3% (SD 0.8). Overall, 64% of participants included (128 out of 200) had a prescription for either SGLT2-inhibitor or GLP-1 agonist at six months. Ultimately, the study showed that a higher proportion of those in the simultaneous education and medication titration arm (81 out of 116) had prescription at six months than those in the sequential “education-first,” followed by medication titration arm (47 out of 84) (70% vs 56% respectively; p<0.001). The study did not demonstrate significant differences in change in A1c (0.3 vs 0.3 respectively; p=0.89) or weight in kilograms (2.5 vs 2.0 respectively; p=0.44) at six months.
In conclusion, the authors conclude that a team-based remote method to educate and prescribe T2DM GDMT can improve utilization and adherence to such therapies for T2DM patients with elevated CV or kidney risk. These findings support the utility of a team-based remote approach (compared to a traditional care approach) and the apparent superiority of education and prescription both simultaneously and longitudinally. Further directions for study and implementation to be considered include remote team-based approaches for other chronic diseases among other populations.