Assessing Patient-Centric Factors and Enhancing Risk Communication to Improve Treatment Persistence in Kidney and Cardiovascular Care

ABSTRACT Sodium glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1RA) are two classes of medications poised to revolutionize chronic kidney disease (CKD) care after repeatedly demonstrating their ability to prevent cardiovascular disease (CVD) and CKD progression in clinical trials. With pleiotropic benefits across type 2 diabetes mellitus (T2DM), CKD, and CVD, these medications are the central therapeutic elements of an ongoing shift in CVD prevention from disjointed risk factor control toward comprehensive, multi-organ care for Cardio-Kidney-Metabolic (CKM) syndrome. This new CKM approach holds great promise for mitigating the CVD risk that threatens over 14 million adults with T2DM and CKD within the U.S.; however, prior work from our group and others indicates that the adoption of SGLT2i and GLP1RA in CKD care is being tragically limited by poor treatment persistence. Achieving the full benefit of these medications will require novel approaches to motivate and reinforce their persistence; however, such undertakings in individuals with T2DM and CKD can be challenging — many are unaware of their diagnosis, providers underestimate their CVD risk, and the unique benefit of these medications may not be fully appreciated among the myriad of other clinical problems that arise in this medically complex, high-risk population. To tackle this enormous challenge, the proposed project will rigorously develop an effective Risk Communication Aid to translate individualized CVD risk estimation and the benefits of SGLT2i and GLP1RA treatment into joint patient-provider efforts to prevent CVD through persistent treatment. We will accomplish these goals by first investigating how the complexity of care in persons with T2DM and CKD is associated with persistent SGLT2i and GLP1RA use across a national integrated health care system using detailed clinical data from the Veterans Health Administration (VHA) (Aim 1). Then, interviews of patients and providers across the landscape of CKM care will contextualize insights from Aim 1 by pinpointing key barriers to persistent treatment using an implementation science framework (Aim 2). Finally, the knowledge gained from Aim 2 and an iterative, stakeholder-driven development process will be used to create a novel CVD Risk Communication Aid to facilitate patient-provider discussions promoting persistent SGLT2i and GLP1RA use. This tool will be piloted in the primary care setting among persons with T2DM and CKD (Aim 3). This proposal will leverage the unique advantages of VHA to develop innovations in healthcare delivery that are minimally influenced by costs to patients. Dr. Ikeme has assembled an unparalleled team of mentors with expertise in CVD risk prediction, innovative kidney care delivery, implementation science, risk communication, and biostatistics. With their guidance, this work will place Dr. Ikeme at the forefront of effective CVD prevention in CKD and lay the foundation for an independent R01-level project evaluating a Risk Communication Aid to improve the persistence of CVD preventive treatment in CKD.