Disparities reported in use of cardioprotective drugs in type 2 diabetes
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Among adults with type 2 diabetes, white men and white women and those seeing an endocrinologist receive more prescriptions for SGLT2 inhibitors and GLP-1 receptor agonists than Black adults and those seen only in primary care, data show.
GLP-1 receptor agonists and SGLT2 inhibitors provide substantial cardiovascular risk reduction for adults with type 2 diabetes and CVD. However, these agents remain underutilized in clinical care, despite guidelines recommending them as first-line therapy for eligible patients, Sadeer G. Al-Kindi, MD, a cardiologist and investigator at Case Western Reserve University School of Medicine, and colleagues wrote.
“We sought to explore contemporary utilization of cardioprotective medications in patients with diagnosed type 2 diabetes and CVD who are under the care of large health care systems in the United States participating in an electronic medical record-based registry,” the researchers wrote.
Al-Kindi and colleagues analyzed data from the cloud-based Explorys/IBM Watson system on 392,130 patients from more than 26 major U.S. health systems with type 2 diabetes and CVD (50% women; 67% white).
Overall, 11.3% of patients received GLP-1 receptor agonists, 11.1% received SGLT2 inhibitors and 17.8% received a GLP-1 receptor agonist or an SGLT2 inhibitor. Prescription rates differed significantly by race and sex: 21.6% of white men, 19.3% of white women, 16.8% of Black women and 14.5% of Black men were prescribed an agent from either class. Rates were similar for GLP-1 receptor agonists and SGLT2 inhibitors separately. Adults with private insurance had higher utilization rates of either drug class, and those with Medicare-only insurance had the lowest utilization rates.
Compared with the overall population, Asian adults had lower prescription rates for GLP-1 receptor agonists and higher for SGLT2 inhibitors, whereas Hispanic adults had higher prescription rates for both drug classes.
Additionally, compared with patients without cardiologist visits, those with cardiologist visits had twice the rate of prescriptions for either drug class. Patients with endocrinologist visits had 3.5 times higher GLP-1 receptor agonist prescription rates, 2.4 times higher SGLT2 inhibitor prescription rates and 2.7 times higher prescription rates for either drug class compared with those who had no endocrinology visits.
Moreover, patients with both cardiologist and endocrinologist visits were 4.9 times more likely to receive a GLP-1 receptor agonist prescription, 3.5 times more likely to receive a SGLT2 inhibitor prescription and 3.8 times more likely to receive a prescription for either drug class compared with those without cardiology or endocrinology visits.
The researchers wrote that these findings reveal the need for studies to identify reasons for therapeutic inertia in the primary care setting and to investigate methods to overcome barriers for prescriptions and eliminate structural racism to promote pharmacoequity. “Many opportunities exist to improve utilization of these medications, including broader insurance coverage and updating the insurance-level appropriateness criteria to mirror those of societal clinical practice guidelines,” the researchers wrote.
They added that opportunities to educate patients and health care providers on the benefit, safety and criteria to identify patients who benefit the most may provide additional increase in utilization.
“Non-physician-driven prescriptions (eg, pharmacy-driven prescribing and dose escalation) may improve utilization rates,” they wrote. “Multidisciplinary care delivery (eg, comprehensive cardiometabolic centers) may additionally improve utilization rates.”
Perspective
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Rarely have we witnessed a more explosive impact of new therapeutic developments than the benefits of GLP-1 receptor agonists and SGLT2 inhibitors on reducing risk for CVD in type 2 diabetes over the past 15 years. Cardiovascular Outcome Trial-based, guideline-directed treatments using these drugs offer the promise of substantial cardioprotective benefit when used in appropriate patients in a timely fashion. The current report by Al-Kindi and colleagues provides important insight into patterns of underutilization of these breakthrough treatments using information from a cloud-based, big data population health management system. This report highlights the impact of the availability of methods to quantify and characterize how paradigm-shifting treatments in chronic disease are being used, by whom, in whom and under what socioeconomic and sociodemographic circumstances.
Multiple insights derive from analysis of these large datasets. First, given the known prevalence of CVD in persons with type 2 diabetes, there is marked overall underutilization of these agents with proven cardioprotective benefits. Furthermore, the patterns of underutilization differ according to provider type, patient ethnicity and sex, and type of insurance coverage. Notably, lower utilization rates of these agents were seen in African Americans, particularly males. Similarly, lower utilization was observed in those persons with Medicare insurance only.
However, two encouraging trends were unmasked in this analysis. First, compared with an earlier study of commercially insured patients, the current data reveal increasing use of these drugs in African Americans, and second, patients with type 2 diabetes who have subspecialty visits with endocrinologists or cardiologists have higher utilization rates — with the highest rates of use occurring in those seen by both specialties. The latter finding may have profound implications related to interdisciplinary care in chronic diseases like type 2 diabetes.
Thus, these data strongly imply that such analytical approaches will be essential to assessment of trends in guideline-directed treatments across populations. Critical insights into drivers of clinical inertia will be obtained, providing direction for policy and practice changes to optimize impact of therapies with proven benefit.
Just as importantly, however, is the inability of these big data platforms to assess the role of biases, patient preferences, or the role of social determinants of health in driving clinical patterns of use of agents like these. Indeed, these data are infrequently and inconsistently captured by EMR systems and, thus, cannot be fully leveraged by large data population health management platforms such as described in this insightful and provocative report. While some questions are certainly being answered in this tangled web of underutilization, a great deal more are rightfully being raised.
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