This article was published on PracticalCardiology.com.
A retrospective cohort study of more than 1.1 million commercially insured patients with diabetes provides an overview of potential racial, ethnic, and socioeconomic inequities in GLP-1 RA use among patients with diabetes in the US, including subanalyses of patients with and without atherosclerotic cardiovascular disease (ASCVD).
The Penn Medicine-led study, which leveraged data from the OptumInsight Clinformatics Data Mart database, provides insight into the use of GLP-1 RA use among insured adults with diabetes, with results suggesting use had improved but remained low among patients with diabetes and demonstrating Asian, Black, and Hispanic patients, as well as those with low income, were less likely to receive treatment with a GLP-1 RA.
“Our study demonstrated significant inequities in use among Black, Latinx, and Asian patients, as well as patients of lower economic status being less likely to be prescribed this therapy. Given well-documented racial disparities in the burden of diabetes and cardiovascular disease, we feel that the differences in utilization of this therapy must be addressed to prevent worsening inequitable outcomes,” said lead investigator Lauren Eberly, MD, a clinical fellow in Cardiovascular Disease at the Perelman School of Medicine at the University of Pennsylvania, in a statement.
Given recent revelations surrounding the cardioprotective effects, the current study was conducted by Eberly and colleagues from the Perelman School of Medicine with an interest in exploring usage rates of GLP-1 RAs among patients with diabetes in the US, with the specific intent of exploring use among a subpopulation of patients with ASCVD. To do so, investigators designed the current study as a retrospective cohort analysis of data from commercially insured adult patients with type 2 diabetes within the OptumInsight Clinformatics Data Mart database from October 1, 2015-June 31, 2019.
Using multivariable logistic regression models, investigators sought to estimate associations of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use. Investigators noted the study period chosen was selected as it reflects a time period when the cardiovascular benefits of GLP-1 RA were clearly known. Investigators pointed out patients were required to have 1 year of continuous enrollment or more before and 6 months or more after study entry for inclusion in the study.
Overall, investigators identified 1,180,260 patients with type 2 diabetes from the database, including 90,934 (7.7%) treated with GLP-1 RAs during the study period. The study cohort had a median age of 69 (IQR, 59-76) years and 50.3% were female. The cohort included 52,349 Asian patients, 146 861 non-Hispanic Black patients, 173,561 Hispanic patients, and 681 579 White patients. The zip code-linked median household income was less than $50,000 for 31.3% of patients, $50,000-99,999 for 29.7% of patients, greater than $100,000 for 17.3% of patients, and unknown for 21.4% of patients.
Upon analysis, investigators found GLP-1 RA use among patients with type 2 diabetes increased from 3.2% in 2015 to 10.7% in 2019. In a subgroup of patients with ASCVD, use increased from 2.8% in 2015 to 9.4% in 2019. In adjusted models, lower rates of GLP-1 RA use were observed for Asian (aOR, 0.59; 95% CI, 0.56-0.62), Black (aOR, 0.81; 95% CI, 0.79-0.83), and Hispanic (aOR, 0.91; 95% CI, 0.88-0.93) patients compared to their White counterparts. Additionally, results suggested female sex (aOR, 1.22; 95% CI, 1.20-1.24) and higher zip code–linked median household incomes (>$100,000 [OR, 1.13; 95% CI, 1.11-1.16]; $50,000-99,999 [OR, 1.07; 95% CI, 1.05-1.09]) were associated with increased likelihood of GLP-1 RA use.
Further analysis among patients with ASCVD revealed similar trends. Specifically, Asian patients (aOR, 0.69; 95% CI, 0.65-0.73), Black patients (aOR, 0.82; 95% CI, 0.79-0.85), and Hispanic patients (aOR, 0.94; 95% CI, 0.91-0.96) were less likely to use GLP-1 RAs than White patients, those with higher median household incomes (>$100,000 and $50,000-$99,999) were more likely to GLP-1 RAs than those with lower income (aOR, 1.06 [95% CI, 1.03-1.08]; aOR 1.15 [95% CI, 1.11-1.18], respectively), and female patients (aOR, 1.18; 95% CI, 1.15-1.20) were more likely to use GLP-1 RAs than male patients.
“While we are unable to ascertain exactly the reasons behind inequitable use, these results persisted after we adjusted for numerous variables, including clinical factors, socioeconomic factors, and even engagement with specialty care – including cardiology and endocrinology,” Eberly added. “Therefore, the results reveal biases in health care delivery, which must be rectified. We feel these results are reflective of structural racism, and unfortunately are one of many examples of how healthcare systems fail to deliver quality care for non-white patients.”
This study, "Racial, Ethnic, and Socioeconomic Inequities in Glucagon-Like Peptide-1 Receptor Agonist Use Among Patients With Diabetes in the US," was published in JAMA Health Forum.