Antidiabetic treatment patterns and specialty care utilization among patients with type 2 diabetes and cardiovascular disease

Abstract

BackgroundTo evaluate real-world patient characteristics, medication use, and health care utilization patterns in patients with type 2 diabetes with established cardiovascular disease (CVD).MethodsCross-sectional analysis of patients with type 2 diabetes seen at Cleveland Clinic from 2005 to 2016, divided into two cohorts: with-CVD and without-CVD. Patient demographics and antidiabetic medications were recorded in December 2016; department encounters included all visits from 1/1/2016 to 12/31/2016. Comorbidity burden was assessed by the diabetes complications severity index (DCSI) score.ResultsOf 95,569 patients with type 2 diabetes, 40,910 (42.8%) were identified as having established CVD. Patients with CVD vs. those without were older (median age 69.1 vs. 58.2 years), predominantly male (53.8% vs. 42.6%), and more likely to have Medicare insurance (69.4% vs. 35.3%). The with-CVD cohort had a higher proportion of patients with a DCSI score ≥ 3 than the without-CVD cohort (65.0% vs. 10.3%). Utilization rates of glucagon-like peptide-1 receptor agonists and sodium–glucose co-transporter-2 inhibitors were low in both with-CVD (4.1 and 2.5%) and without-CVD cohorts (5.4 and 4.1%), respectively. The majority of patient visits (75%) were seen by a primary care provider. During the 1-year observation period, 81.9 and 62.0% of patients with type 2 diabetes and CVD were not seen by endocrinology or cardiology, respectively.ConclusionsThese data indicated underutilization of specialists and antidiabetic medications reported to confer CV benefit in patients with type 2 diabetes and CVD. The impact of recently updated guidelines and cardiovascular outcome trial results on management patterns in such patients remains to be seen.

The prevalence of cardiovascular disease and antidiabetes treatment characteristics among a large type 2 diabetes population in the United States

“…In the total Cleveland Clinic study population, usage of GLP‐1RAs and SGLT2is was each <5.5%, and even lower in the ASCVD group. The majority of patients (>80%) had not had an endocrinology visit in the past year …”

“…Findings from the current analysis are consistent with those of a recent similar cross‐sectional analysis based on electronic health record data from Cleveland Clinic (Ohio and Florida) for the year 2016 . The Cleveland Clinic study included data from 96 569 individuals with T2DM and reported that 42.8% had CVD, which is highly consistent with the proportion with established ASCVD in the current study.…”

“…The majority of patients (>80%) had not had an endocrinology visit in the past year. 12 As previously noted, improved cardiovascular outcomes in patients with T2DM and CVD treated with empagliflozin and liraglutide were demonstrated in the EMPA-REG-OUTCOME and LEADER trials, respectively, 8,9 which led to the ADA recommending empagliflozin and liraglutide in patients with long-standing sub-optimally controlled T2DM and ASCVD in 2017. 4 Additional CV outcomes data with the use of GLP-1RA and SGLT2i drug classes in patients with T2DM have shown benefits with the SGLT2i, canagliflozin, 15 and the GLP-1RA, semaglutide.…”

“…The impact of the updated diabetes guidelines regarding GLP‐1RA and SGLT2i use in at‐risk patients in real‐world clinical practice will be of interest in the coming years. A recent study used the electronic health record system at Cleveland Clinic (Ohio and Florida) to create a cross‐sectional summary of patients with T2DM and CVD in 2016 (ie the year prior to release of the 2017 ADA guidelines) to establish a baseline of real‐world treatment patterns in these patients . Utilization rates of GLP‐1RA and SGLT2i agents were found to be low (<10%) in patients with T2DM, whether with or without established CVD.…”

Performance of a computable phenotype for identification of patients with diabetes within PCORnet: The Patient‐Centered Clinical Research Network

“…Consequently, the performance of our CP for identification of incident T2DM was very poor. As noted in prior research, identification of patients with T2DM within large health care systems does not always indicate that such systems are the primary or initial site of diabetes management . As outlined in a recent study, requiring at least one encounter coded as primary care or endocrinological/diabetes in each of the prior 2 years might better differentiate incident or new onset T2DM from patients with prevalent T2DM .…”