Closing the Cardio-Renal Preventive Treatment Gap Among Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: An Implementation Science Approach

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Project Summary/Abstract Individuals with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) have an extremely high risk of cardiovascular disease (CVD). However, they are not optimally prescribed evidence-based cardio-renal preventive therapies that could considerably reduce such risk. These therapies, which include angiotensin- converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARB), glucagon-like peptide-1 receptor agonists (GLP1) and sodium-glucose co-transporter 2 inhibitors (SGLT2i), substantially lower CVD risk and the risk of CKD progression. Thus, their optimal prescription could lead to marked reductions in the CVD burden of patients with T2DM and CKD. In the mentored phase of the award, the proposed research will investigate the major factors accounting for the under-prescription of cardio-renal preventive therapies among patients with T2DM and CKD. To accomplish this, we will conduct mixed-methods research combining quantitative analyses with qualitative explorations. Specifically, in Aim 1 we will leverage a dataset of over 1.5 million patients with T2DM in the Veterans Affairs (VA) system to identify multi-level predictors of prescription of cardio-renal preventive therapies. In Aim 2, we will conduct focus groups with patients and providers to qualitatively explore contextual determinants of the under-prescription of cardio-renal preventive therapies. In the independent phase of the award (Aim 3), we will leverage findings form Aims 1 and 2 to implement an educational intervention aimed at improving primary care providers’ knowledge and self-efficacy regarding cardio-renal preventive therapies in one medical facility. The components of the educational intervention are: 1) an educational toolkit consisting of an informational booklet, fact sheets/infographics, and informational posters for use in clinics; 2) primary care provider champions who will serve as reference providers regarding prescription of cardio-renal preventive therapies; and 3) interdisciplinary case-conferences regarding appropriate prescription of cardio-renal therapies. We will evaluate the change of primary care providers’ knowledge and self-efficacy before and after the intervention and compare changes in the rates of prescription of cardio-renal preventive therapies with a “passive” control medical facility. The completion of the proposed research and training in implementation science and mixed-methods research will be instrumental to establish Dr. Lamprea Montealegre’s independent research career at the intersection of CVD epidemiology and implementation science. In particular, the new set of skills in implementation science will allow Dr. Lamprea Montealegre to lead research and clinical programs on CVD prevention through the systematic detection and treatment of CKD, and to become a national leader in preventive cardio-renal care.