Aim: Type 2 Diabetes (T2D) is a major cause of morbidity and mortality. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are highly effective but underutilized. We assessed racial/ethnic and other sociodemographic disparities in GLP-1/SGLT-2 use among US adults with T2D. Materials and Methods: We conducted a retrospective analysis using nationally representative data from National Health and Nutrition Examination Survey 2005-March 2020. Participants were adults with T2D taking ≥1 diabetes medication, excluding pregnant women and adults with probable T1D. We performed univariate analyses to examine characteristics of patients using GLP-1/SGLT-2 and multivariable logistic regression to assess disparities in GLP-1/SGLT-2 use after adjusting for other patient factors. Results: Among 4,585 T2D patients (representing >18 million US adults) taking ≥1 medication, GLP-1/SGLT-2 usage increased from 1.4% in 2005-2006 to 13.3% in 2017-2020. In univariate analyses, patients using GLP-1/SGLT-2 vs. other T2D drugs were more likely to be white than nonwhite (72% vs. 60%, p = .001), but in multivariable analysis there was no significant difference in GLP-1/SGLT-2 use for nonwhite vs. white patients (aOR = 0.84, 95% CI [0.61, 1.16]). GLP-1/SGLT-2 use was higher for patients who completed some college (aOR = 1.83, 95% CI [1.06, 3.15]) or above (aOR = 2.06, 95% CI [1.28, 3.32]) vs. high school or less, and for those with an income-poverty ratio ≥4 vs. <2 (aOR = 2.11, 95% CI [1.30, 3.42]). Conclusions: Use of GLP-1/SGLT-2 drugs increased over time but remained low in March 2020. Higher education and income, but not race/ethnicity, were associated with GLP-1/SGLT-2 use.
Background: Venous thromboembolism (VTE) is the leading cause of preventable hospital death in the US. Guidelines from the American College of Chest Physicians and American Society for Hematology recommend providing pharmacological VTE prophylaxis to acutely or critically ill medical patients at acceptable bleeding risk, but there is currently only one validated risk assessment model (RAM) for estimating bleeding risk. We developed a RAM using risk factors at admission and compared it with the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model. Methods: A total of 46,314 medical patients admitted to a Cleveland Clinic Health System hospital from 2017-2020 were included. Data were split into training (70%) and validation (30%) sets with equivalent bleeding event rates in each set. Potential risk factors for major bleeding were identified from the IMPROVE model and literature review. Penalized logistic regression using LASSO was performed on the training set to select and regularize important risk factors for the final model. The validation set was used to assess model calibration and discrimination and compare performance with IMPROVE. Bleeding events and risk factors were confirmed through chart review. Results: The incidence of major in-hospital bleeding was 0.58%. Active peptic ulcer (OR = 5.90), prior bleeding (OR = 4.24), and history of sepsis (OR = 3.29) were the strongest independent risk factors. Other risk factors included age, male sex, decreased platelet count, increased INR, increased PTT, decreased GFR, ICU admission, CVC or PICC placement, active cancer, coagulopathy, and in-hospital antiplatelet drug, steroid, or SSRI use. In the validation set, the Cleveland Clinic Bleeding Model (CCBM) had better discrimination than IMPROVE (0.86 vs. 0.72, p < .001) and, at equivalent sensitivity (54%), categorized fewer patients as high-risk (6.8% vs. 12.1%, p < .001). Conclusions: From a large population of medical inpatients, we developed and validated a RAM to accurately predict bleeding risk at admission. The CCBM may be used in conjunction with VTE risk calculators to decide between mechanical and pharmacological prophylaxis for at-risk patients.
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