Racial, Ethnic, and Socioeconomic Inequities in Glucagon-Like Peptide-1 Receptor Agonist Use Among Patients With Diabetes in the US

Abstract

IMPORTANCE Randomized clinical trials have shown that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) cause significant weight loss and reduce cardiovascular events in patients with type 2 diabetes (T2D). Black patients have a disproportionate burden of obesity and cardiovascular disease and have a higher rate of cardiovascular-related mortality. Racial and ethnic disparities in health outcomes are largely attributable to the pervasiveness of structural racism, and patients who are marginalized by racism have less access to novel therapeutics.OBJECTIVES To evaluate GLP-1 RA uptake among a commercially insured population of patients with T2D; identify associations of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use; and specifically examine its use among the subgroup of patients with atherosclerotic cardiovascular disease (ASCVD) because of the known benefit of GLP-1 RA use for this population. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort analysis using data fromOptumInsight Clinformatics Data Mart of commercially insured adult patients with T2D (with or without ASCVD) in the US. Data from October 1, 2015, to June 31, 2019, were included, and the analyses were performed in July 2020. We estimated multivariable logistic regression models to identify the association of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use. MAIN OUTCOME AND MEASUREA prescription for a GLP-1 RA. RESULTSOf the 1 180 260 patients with T2D (median [IQR] age,[69][70][71][72][73][74][75][76] years; 50.3% female; 57.7% White), 90 934 (7.7%) were treated with GLP-1 RA during the study period. From 2015 to 2019, the percentage of T2D patients treated with an GLP-1 RA increased from 3.2% to 10.7%. Among patients with T2D and ASCVD, use also increased but remained low (2.8%-9.4%). In multivariable analyses, lower rates of GLP-1 RA use were found among Asian (aOR, 0.59; 95% CI, 0.56-0.62), Black

County-level variation in cardioprotective antihyperglycemic prescribing among medicare beneficiaries

“…Previous studies have demonstrated disparities in SGLT2i and GLP-1RA utilization at the individual level. Data from national surveys as well as those from large private insurers and the Veterans Affairs healthcare system found patterns suggestive of lower SGLT2i and GLP1-RA prescribing for individual Black patients [ 23 – 26 ]. This was observed in a national British report as well [ 27 ].…”

“…Additionally, while we used metformin prescriptions as a surrogate for patients being actively managed for type 2 diabetes, the use of metformin for other indications, including prediabetes and polycystic ovarian syndrome, may be reflected in modest reductions in the observed use of SGLT2i and GLP1-RA as compared to metformin. However, the vast majority of metformin use is for patients with established type 2 diabetes as less than 1% of those with prediabetes are prescribed metformin and it is no longer strongly recommended for polycystic ovarian syndrome, and is therefore, unlikely to substantially affect our observations [ 37 , [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] ]. Finally, identifying counties based on city and state is slightly imprecise given variations in how administrative divisions are defined (e.g.…”

Beyond Detecting and Understanding Disparities in Novel Diabetes Treatment

“…In a study based on a large, retrospective cohort of commercial health insurance and Medicare Advantage health plan enrollees with type 2 diabetes, Eberly et al showed that Asian individuals and Black individuals were less likely than non-Hispanic White individuals to be prescribed SGLT2i from 2015 to 2019. In a separate analysis, using the same study design, data sources, and time frame, these authors also showed that Asian, Black, and Hispanic individuals were significantly less likely to be prescribed GLP-1 RA . Higher zip code–linked median household income and commercial insurance vs Medicare Advantage insurance were significantly associated with higher rates of SGLT2i and GLP-1 RA prescribing, suggesting that lack of affordability and prohibitive out-of-pocket costs for these medications could lead to preferential use of less expensive and generically available hypoglycemic medications and account for the observed treatment disparities.…”

Reframing the need for exercise therapy in the clinical management of people living with obesity

“…While over time the cost of these medications will decrease patients are currently faced with a daunting financial challenge if they wish to commence and necessarily maintain treatment over the lifespan 33 . Racial, ethnic and socioeconomic inequalities regarding GLP‐1 agonist use patients with type 2 diabetes within the United States has been recently described 34 . Thus prior to improvements in insurance coverage and the necessary education of some primary care providers, treatment of obesity with novel GLP‐1 agonists will be observed in a small percentage of those living with the disease.…”

“…33 Racial, ethnic and socioeconomic inequalities regarding GLP-1 agonist use patients with type 2 diabetes within the United States has been recently described. 34 Thus prior to improvements in insurance coverage and the necessary education of some primary care providers, treatment of obesity with novel GLP-1 agonists will be observed in a small percentage of those living with the disease.…”