SGLT2i prescriptions vary among US Veterans Affairs facilities
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Disparities by sex, race and between individual U.S. Veterans Affairs facilities exist in SGLT2i prescriptions for veterans with chronic kidney disease, type 2 diabetes mellitus and atherosclerotic cardiovascular disease, researchers found.
According to data published in the American Journal of Kidney Diseases, researchers could not explain the variations among the facilities.
“In the setting of the increasing body of evidence supporting their benefits, SGLT2i prescription was adopted in the Veterans Affairs (VA) Health Care System for individuals with [type 2 diabetes mellitus] T2DM and comorbid CKD, atherosclerotic cardiovascular disease (ASCVD), or heart failure with reduced ejection fraction. Many patients receiving VA care, therefore, have access to these prescriptions without concern for high out-of-pocket cost,” L. Parker Gregg, MD, MSCS, from the Selzman Institute for Kidney Health in the section of nephrology at Baylor College of Medicine in Texas, and colleagues wrote.
“Nevertheless, studies show that these agents are underutilized, likely due to multiple barriers related to guidelines, clinicians and patient-level factors, as has been seen with other medication classes.”
In a retrospective cohort, researchers examined data of 174,443 U.S. veterans with CKD, T2DM and ASCVD to determine SGLT2i prescription patterns. Patients received a primary care visit between Jan. 1 and Dec. 31, 2020, and data were derived from the U.S. VA Corporate Data Warehouse. With SGLT2i prescription serving as the primary outcome, researchers considered race, sex and individual VA location as exposures of the study.
Using multivariable logistic regression, researchers measured the relationship between race and sex with SGLT2i prescriptions. Additionally, researchers quantified facility-level variation in SGLT2i prescriptions with median rate ratios.
Overall, 11.5% of veterans were prescribed an SGLT2i. Researchers identified a higher chance of white patients receiving an SGLT2i prescription than Black or African American patients, as 80% of SGTL2i users were white and 12.3% were Black or African American. A similar trend was seen with men compared with women.
Analyses revealed the adjusted median ratio rate for SGLT2i prescriptions was 1.58 in the whole cohort. Therefore, a 58% variation in treatment exists between VA facilities, which researchers were unable to explain.
“Ultimately, this variability may be explained by unmeasurable phenomena at the level of individual clinicians, such as their familiarity with indications and contraindications, their understanding of the benefits seen in clinical trials and their confidence regarding recognizing and appropriately managing adverse effects, suggesting the need for additional education about the benefits of these agents,” Gregg and colleagues wrote. They added, “Reasons underlying racial and sex disparities must be identified and addressed to ensure equitable access to these important medications. Further, health services research should address barriers to SGLT2i prescription to increase guideline-based practice to improve long-term cardiovascular and kidney outcomes in patients with CKD.”
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