Enhancing the use of sodium-glucose cotransporter-2 inhibitors in type-2 diabetic patients with chronic kidney disease, through a key performance indicator program

Background: Despite substantial clinical evidence and recommendations from international societies supporting the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) for managing patients with type-2 diabetes (T2D) and chronic kidney disease (CKD), their adoption has remained limited. To address this, the nephrology quality improvement (QI) team at Hamad Medical Corporation (HMC), Qatar, implemented a key performance indicator (KPI) program in March 2022, aiming to ensure that at least 80% of eligible T2D-CKD patients at HMC were receiving SGLT2i by December 31, 2023. Methods: The use of SGLT2i and angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) in T2D-CKD patients attending nephrology clinics at HMC hospitals were assessed through retrospective surveys using a cluster-based sampling approach. Nephrology physicians were then updated on the results of these retrospective surveys as well as evidence from the SGLT2i trial and guidelines. The aims, objectives, and targets of the KPI program were clearly defined. Three additional surveys were conducted at 6-month intervals. A multifaceted QI intervention approach—combining audit, feedback, leadership engagement, and peer consultation—was implemented to drive improvement. Results: Retrospective surveys conducted in November 2021 and February 2022 revealed that 38% and 44% of eligible T2D-CKD patients were receiving SGLT2i therapy, compared to 98% and 99% for ACEi/ARB. Four months after implementing the KPI program, the July 2022 survey revealed no change in SGLT2i use (41%), while ACEi/ARB prescription rates remained near 100%. Following QI interventions in November 2022, the February 2023 survey revealed a significant increase in SGLT2i use, rising to 88%, with SGLT2i initiation in naive patients increasing from 34% to 61%. The final survey conducted in August 2023 showed that 84% of patients were receiving SGLT2i therapy. Conclusion: Our KPI program boosted SGLT2i prescription rates for eligible T2D-CKD patients in nephrology clinics, resulting in a 47% rise from 41% to 88%. It overcame prescription inertia and accelerated the guideline adoption by combining real-time feedback, leadership engagement, and peer discussions. The sharp rise in new prescriptions following November 2022 feedback underscores its direct influence on behavior modification rather than a broader trend.