Multidisciplinary electronic consultation to improve evidence-based care for patients with diabetic kidney disease

PROJECT SUMMARY/ABSTRACT Diabetic kidney disease (DKD) is the leading cause of end stage kidney disease (ESKD). Despite evidence that sodium-glucose cotransporter-2 inhibitors (SGLT2i) and renin and angiotensin system inhibitors (RAASi) can reduce of risk of ESKD in patients with diabetes, prescription rates remain low. This R03 proposal is responsive to SEN NOT-HS-19-011: Health Services Research Priorities for Achieving a High Value Healthcare System which specifically addresses “transforming kidney care” and “reinventing primary care.” The goal of this study is to finalize and assess the implementation and preliminary effectiveness of the Multidisciplinary Diabetic Kidney Disease Program (MDKDP), a population health strategy developed at Montefiore, to assure evidence-based care for patients with DKD. MDKDP is designed to overcome known barriers to prescribing RAASi and SGLT2i by primary care providers (PCPs) for patients with high-risk DKD. MDKDP is composed of three implementation strategies: 1) a dashboard of patients with high-risk DKD (High-risk DKD Dashboard) allowing the proactive targeting of patients not receiving evidence-based treatment, 2) multidisciplinary collaboration between endocrinologists, nephrologists and PCPs, and 3) use of a novel population health strategy where endocrinologists and nephrologists initiate contact with PCPs using an electronic consultation (e-consult) for patients with treatment gaps identified on the High-risk DKD Dashboard. The content of the MDKDP e-consult will be customized for individual patients and include recommendations for use of RAASi and/or SGLT2i and modification of currently prescribed diabetes and hypertension medications. There are three potential outcomes following a MDKDP e-consult: 1) PCP-initiated change in treatment, 2) PCP request for co-management through a patient appointment with the specialist team or 3) no changes. The specific aims of this proposal are 1) to finalize MDKDP by identifying the factors which may affect the implementation of MDKDP and actionable recommendations for modifying the implementation strategies and 2) to assess the implementation outcomes of adoption, acceptability, appropriateness and feasibility and evaluate preliminary effectiveness defined as PCP-initiated change in SGLT2i and/or RAASi prescription or request for co- management. We will perform qualitative analysis of focus groups with physician stakeholders to finalize MDKDP, pilot test MDKDP for 20 PCP-patient pairs, and perform qualitative analysis of interviews with pilot trial participants. This R03 will allow the study team to rigorously evaluate MDKDP to assess the degree to which it is successful in implementing evidence-based treatments for a population at high risk for progression to ESKD. Based on outcomes, the research team will prepare a future, large RCT designed to scale the intervention and evaluate patient outcomes including blood pressure, hemoglobin A1C, and DKD progression. MDKDP is generalizable to U.S. institutions experiencing gaps in evidence-based treatments for DKD and the use of e- consults for population health management can be adapted to other high yield evidence-based practices.