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. 2022 Aug 2:11:100370.
doi: 10.1016/j.ajpc.2022.100370. eCollection 2022 Sep.

County-level variation in cardioprotective antihyperglycemic prescribing among medicare beneficiaries

Jonathan Hanna  1 , Arash A Nargesi  1 , Utibe R Essien  2   3 , Veer Sangha  4 , Zhenqiu Lin  5   6 , Harlan M Krumholz  5   6   7 , Rohan Khera  5   6   8
Affiliations

County-level variation in cardioprotective antihyperglycemic prescribing among medicare beneficiaries

Jonathan Hanna et al. Am J Prev Cardiol. .

Abstract

Background: Cardioprotective antihyperglycemic agents, SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1RA), improve outcomes of patients with type 2 diabetes, but adoption has been limited. Differences across individuals have been noted but area-level variation is unknown.

Objectives: Given healthcare access and sociodemographic differences, we evaluated whether SGLT2i and GLP-1RA utilization varies across US counties.

Methods: We linked 2019 Medicare Part D national prescription data with county-level demographic measures from the Agency for Health Quality and Research. We compared the number of beneficiaries receiving prescriptions for any cardioprotective antihyperglycemic to the number receiving metformin prescriptions across US counties. In multivariable linear regression with SGLT2i-to-metformin and GLP1RA-to-metformin prescriptions as outcomes, we evaluated county factors associated with use of cardioprotective agents while adjusting for sociodemographic measures, region, and cardiometabolic risk factor prevalence.

Results: In 3066 US counties, there were a median 2,416 (IQR, 1681-3190) metformin-receiving beneficiaries per 100,000 population. A median 6.2% of beneficiaries receiving metformin received SGLT2i therapy, varying across counties (IQR, 3.4%-9.2%). A median 9.4% (IQR, 5.0%-13.0%) of beneficiaries receiving metformin received GLP-1RA. In adjusted analyses, higher percentage of Black population was associated with lower use at the county level of people on SGLT2i or GLP-1RA relative to metformin (a SD higher proportion of Black individuals with 0.4% [95% CI, -0.6% to -0.1%] and 0.5% [-0.8% to -0.2%] lower SGLT2i and GLP-1RA prescribing relative to metformin, respectively; P < 0.01). A higher median age of county residents, rural location, and lower prevalence of diabetes were associated with lower SGLT2i prescribing. Similarly, more advanced age of county residents, rural location, proportion of Hispanic individuals, and household income and lower education levels were associated with lower GLP-1RA prescribing. Prescribing was higher in the Northeast and lower in the West as compared with the Midwest for both classes.

Conclusion: There was large variation by county in cardioprotective antihyperglycemic prescribing, with a pattern of lower use in Black-predominant and rural counties, highlighting the critical need to investigate equity in uptake of novel therapeutic agents.

Keywords: CI, confidence interval; GLP-1RA, glucagon-like peptide-1 receptor agonists; Glucagon like peptide-1 receptor agonists; IQR, interquartile range; Medicare; PCP, primary care physicians; Prescription fill; SGLT2i, sodium-glucose cotransporter-2 inhibitors; Sodium glucose cotransporter-2 inhibitors.

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Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rohan Khera reports a relationship with Bristol-Myers Squibb that includes: funding grants. Rohan Khera reports a relationship with National Heart Lung and Blood Institute that includes: funding grants. Rohan Khera reports a relationship with Doris Duke Charitable Foundation that includes: funding grants. Harlan Krumholz reports a relationship with UnitedHealth Group that includes: consulting or advisory. Harlan Krumholz reports a relationship with IBM Watson Health that includes: board membership. Harlan Krumholz reports a relationship with Element Science that includes: consulting or advisory. Harlan Krumholz reports a relationship with Aetna Inc that includes: consulting or advisory. Harlan Krumholz reports a relationship with Facebook that includes: consulting or advisory. Harlan Krumholz reports a relationship with F-Prime that includes: consulting or advisory. Harlan Krumholz reports a relationship with Siegfried & Jensen Law Firm that includes: consulting or advisory. Harlan Krumholz reports a relationship with Arnold & Porter Law Firm that includes: consulting or advisory. Harlan Krumholz reports a relationship with Martin Baughman Law Firm that includes: consulting or advisory. Harlan Krumholz reports a relationship with National Center for Cardiovascular Diseases, Beijing that includes: consulting or advisory. Harlan Krumholz reports a relationship with Centers for Medicare and Medicaid Services that includes: employment. Harlan Krumholz reports a relationship with Medtronic Inc that includes: funding grants. Harlan Krumholz reports a relationship with US Food and Drug Administration that includes: funding grants. Harlan Krumholz reports a relationship with Johnson & Johnson that includes: funding grants. Harlan Krumholz reports a relationship with Shenzhen Center for Health Information that includes: funding grants. Rohan Khera has patent #63/177,117 pending to Rohan Khera. Cofounder of HugoHealth and Refactor Health - HK; Founder of Evidence2Health - RK

Figures

Image, graphical abstract
Graphical abstract
Fig. 1
Fig. 1
Inclusion and exclusion flow diagram.
Fig. 2
Fig. 2
Variation of Antihyperglycemic Therapy Across United States Counties. Histograms of the number of Medicare beneficiaries per 100,000 population in U.S. counties receiving (A) metformin, (B) sodium glucose cotransporter 2 inhibitors (SGLT2i), (C) glucagon-like peptide-1 receptor agonists (GLP-1RA).
Fig. 3
Fig. 3
Geospatial Representation of Cardioprotective Antihyperglycemic Prescribing across States. (A) represents state SGLT2i-receiving beneficiaries as a percent of metformin-receiving beneficiaries, (B) represents the same for GLP-1RA. SGLT2i = sodium glucose cotransporter 2 inhibitors, GLP-1RA = glucagon-like peptide-1 receptor agonists.
Fig. 4
Fig. 4
County Characteristics and SGLT2i Prescribing. Association of county characteristics with county-level prescribing of SGLT2i relative to metformin. Spearman's Rank test is given for each association. SGLT2i = sodium glucose cotransporter 2 inhibitors (SGLT2i), PCPs = primary care physicians.
Fig. 5
Fig. 5
County Characteristics and GLP-1RA Prescribing. Association of county characteristics with county-level prescribing of GLP-1RA relative to metformin. Spearman's Rank test for each association is given. GLP-1RA = glucagon-like peptide-1 receptor agonists, PCPs = primary care physicians.
Fig. 6
Fig. 6
Independent Association of Cardioprotective Antihyperglycemic Prescribing. Results from multivariable regression models. The plot displays regression coefficients and 95% confidence intervals, standardized to one standard deviation change in the independent variable, for each county characteristic. SGLT2i = sodium glucose cotransporter 2 inhibitors, GLP-1RA = glucagon-like peptide-1 receptor agonists.
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