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. 2023 Jan;25(1):282-292.
doi: 10.1111/dom.14874. Epub 2022 Nov 2.

Ethnic and socioeconomic disparities in initiation of second-line antidiabetic treatment for people with type 2 diabetes in England: A cross-sectional study

Patrick Bidulka  1 , Rohini Mathur  1 , David G Lugo-Palacios  2 , Stephen O'Neill  2 , Anirban Basu  3 , Richard J Silverwood  4 , Paul Charlton  5 , Andrew Briggs  2 , Liam Smeeth  1 , Amanda I Adler  6 , Ian J Douglas  1 , Kamlesh Khunti  7 , Richard Grieve  2
Affiliations

Ethnic and socioeconomic disparities in initiation of second-line antidiabetic treatment for people with type 2 diabetes in England: A cross-sectional study

Patrick Bidulka et al. Diabetes Obes Metab. 2023 Jan.

Abstract

Aims: To assess any disparities in the initiation of second-line antidiabetic treatments prescribed among people with type 2 diabetes mellitus (T2DM) in England according to ethnicity and social deprivation level.

Materials and methods: This cross-sectional study used linked primary (Clinical Practice Research Datalink) and secondary care data (Hospital Episode Statistics), and the Index of Multiple Deprivation (IMD). We included people aged 18 years or older with T2DM who intensified to second-line oral antidiabetic medication between 2014 and 2020 to investigate disparities in second-line antidiabetic treatment prescribing (one of sulphonylureas [SUs], dipeptidyl peptidase-4 [DPP-4] inhibitors, or sodium-glucose cotransporter-2 [SGLT2] inhibitors, in combination with metformin) by ethnicity (White, South Asian, Black, mixed/other) and deprivation level (IMD quintiles). We report prescriptions of the alternative treatments by ethnicity and deprivation level according to predicted percentages derived from multivariable, multinomial logistic regression.

Results: Among 36 023 people, 85% were White, 10% South Asian, 4% Black and 1% mixed/other. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by ethnicity were 21% (95% confidence interval [CI] 19-23%), 20% (95% CI 18-22%), 19% (95% CI 16-22%) and 17% (95% CI 14-21%) among people with White, South Asian, Black, and mixed/other ethnicity, respectively. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by deprivation were 22% (95% CI 20-25%) and 19% (95% CI 17-21%) for the least deprived and the most deprived quintile, respectively. When stratifying by prevalent cardiovascular disease (CVD) status, we found lower predicted percentages of people with prevalent CVD prescribed SGLT2 inhibitors compared with people without prevalent CVD across all ethnicity groups and all levels of social deprivation.

Conclusions: Among people with T2DM, there were no substantial differences by ethnicity or deprivation level in the percentage prescribed either SGLT2 inhibitors, DPP-4 inhibitors or SUs as second-line antidiabetic treatment.

Keywords: ethnicity; oral antidiabetics; pharmacoepidemiology; socioeconomic deprivation; type 2 diabetes.

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Conflict of interest statement

All authors have completed an ICJME form. Patrick Bidulka, Stephen O'Neill, Anirban Basu, Richard Silverwood and Liam Smeeth have nothing to declare. Kamlesh Khunti has acted as a consultant, speaker or received grants for investigator‐initiated studies for Astra Zeneca, Novartis, Novo Nordisk, Sanofi‐Aventis, Lilly and Merck Sharp & Dohme, Boehringer Ingelheim, Bayer, Berlin‐Chemie AG / Menarini Group, Janssen and Napp. Rohini Mathur has received consulting fees from AMGEN. Paul Charlton sat on an NIHR HTA Commissioning Committee member until September 2021. Anirban Basu is an economic advisor on the DiRECT trial, with ongoing responsibility for economic analysis during the long‐term follow‐up phase, and has also acted as consultant to GlaxoSmithKline, Merck, Novo Nordisk and Boehringer Ingelheim in relation to their diabetes products. Amanda Adler receives salary from the NIHR BRC via the Oxford Centre for Diabetes, Endocrinology and Metabolism. Ian Douglas holds an unrestricted research grant from GSK and holds shares in GSK. Richard Grieve sits on the NIHR commissioning committee.

Figures

FIGURE 1
FIGURE 1
Flow diagram illustrating selection of study population diagnosed with type 2 diabetes mellitus (T2DM) and initiating second‐line antidiabetic treatment. eGFR, estimated glomerular filtration rate; HES, Hospital Episodes Statistics.
FIGURE 2
FIGURE 2
Adjusted predicted percentages of second‐line antidiabetic treatment prescribed, according to ethnicity or deprivation. P values are generated from joint tests comparing the adjusted predicted percentages for being prescribed a particular second‐line antidiabetic drug (a sulphonylurea [SU], a dipeptidyl peptidase‐4 [DPP‐4] inhibitor or a sodium‐glucose cotransporter‐2 [SGLT2] inhibitor) across ethnic groups or across deprivation levels. Predicted percentages are mutually adjusted for deprivation (ethnicity estimates) and ethnicity (deprivation estimates), as well as the number of patients registered at the patient's general practice, years on first‐line treatment category, age category, sex, last glycated haemoglobin value prior to second‐line treatment initiation category, body mass index, prevalent heart failure, ischaemic heart disease, myocardial infarction, stroke, unstable angina, renin‐angiotensin system inhibitors and/or statin co‐prescription, chronic kidney disease category, blood pressure category, history of proteinuria, blindness, cancer (any), hospitalization (any) in past year, smoking status, alcohol status, region, all as fixed effects, and Clinical Commissioning Group‐clustering as a random effect.
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