Analysis Highlights Disparities in GLP-1 RA Access

Racial, ethnic, and socioeconomic inequities exist when it comes to access to glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among US patients with diabetes, according to results of a 5-year cohort study. Findings were published in JAMA Health Forum.

Clinical trials have proven GLP-1 RAs are effective in preventing cardiovascular events in patients with type 2 diabetes (T2D), and especially in those with established atherosclerotic cardiovascular disease (ASCVD). In addition, cardiovascular disease serves as the leading cause of mortality and morbidity among patients with T2D in the United States.

“The American Diabetes Association updated guidelines and the American College of Cardiology expert consensus statement now recommend a GLP-1 RA with demonstrated cardiovascular benefit for patients with diabetes and established or at very high risk for ASCVD,” authors wrote.

However, racial disparities in diabetes rates have been well documented in the past, a phenomenon compounded by inequitable quality of care by race and ethnicity. “Cardiovascular therapeutics with proven benefit are underused among Black and Hispanic patients, even among those who are commercially insured,” researchers added.

In an effort to better understand GLP-1 RA uptake among commercially insured populations with T2D and among those with ASCVD, investigators at the University of Pennsylvania conducted a retrospective cohort study using data from the OptumInsight Clinformatics Data Mart database.

The dataset is made up of payer claims from recipients of commercial health insurance and Medicare Advantage health plans. Over 17 million patients from all 50 states are represented in the dataset annually.

All individuals were at least 18 years old and had a diagnosis of T2D between October 2015 and December 2018. Investigators assessed the datasets for prescription claims for albiglutide, dulaglutide, exenatide, exenatide extended-release, liraglutide, lixisenatide, or semaglutide. Any individual without pharmacy claims for medication for 1 year prior to the study period was excluded.

A total of 1,180,260 patients in the database had a T2D diagnosis and met inclusion criteria. Of these, 4.4% were Asian, 12.4% were Black, 14.7% were Hispanic and 57.7% were White; 90,934 patients (7.7%) were treated with GLP-1 RAs during the study period.

Analyses revealed:

• 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 (adjusted odds ratio [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 with T2D
• 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] and $50,000-$99,999 [OR, 1.07; 95% CI, 1.05-1.09] vs <$50,000) were associated with higher GLP-1 RA use

Results were similar to those found among patients with ASCVD. Coronary artery disease presence and cerebrovascular disease presence were both independently linked with lower GLP-1 RA use.

“Structural racism, defined as the differential distribution of goods, services, and opportunities of society based on race, is a major barrier to achieving health equity,” authors explained. “Patients of racial and ethnic minority groups consistently have inequitable access to guideline-based therapeutics that improve cardiovascular disease burden and outcomes, despite often experiencing a disproportionately higher rate of these conditions.”

Because study findings pointed to inequities independent of clinical factors and in a 100% commercially insured population, findings reveal biases in health care delivery, researchers said.

A better understanding of barriers to GLP-1 RA use among Black patients is warranted as, since 1990, the diabetes-related risk for coronary heart disease has declined among White patients but has doubled among Black patients.

More research is also needed to understand why female sex was associated with higher GLP-1 RA use in this study.

“The factors and clinical decision-making that drive the decision to initiate a certain therapy, such as GLP-1 RA can be complex and are not well-characterized in an administrative database,” authors wrote, citing this fact as a limitation to the analysis. Contraindications and adverse events associated GLP-1 RA use may also have impacted results.

Overall, “we found an independent association of lower GLP-1 RA use among Asian, Black, and Hispanic patients and among those with lower zip code–linked household income, with a similar pattern of inequitable use among patients who also had ASCVD,” they concluded. “Implementation of strategies to ensure more equitable use of GLP-1 RA therapy is warranted.”

Reference

Eberly LA, Yang L, Essien UR, et al. Racial, ethnic, and socioeconomic inequities in glucagon-like peptide-1 receptor agonist use among patients with diabetes in the US. JAMA Health Forum. Published online December 17, 2021. doi:10.1001/jamahealthforum.2021.4182