Race, socioeconomic status associated with lower SGLT2 inhibitor use

Abstract

If you are wondering what health care disparities might look like in medication use for chronic diseases, a new study published in JAMA Network Open can serve as just one example. Among patients with diabetes in the United States, researchers found that lower rates of SGLT2 inhibitor use, a medication with substantial cardioprotective and kidney protective benefits, is associated with Black race, Asian race, female gender, and lower household income. “If left unaddressed, these inequities in [use] will continue to widen well-documented disparities in cardiovascular and kidney outcomes in the U.S.,” said lead study author Lauren Eberly, MD, MPH, a cardiology fellow at the University of Pennsylvania. “Out of pocket costs for these medications are unaffordable for many patients. We hope that pharmacists and other clinicians can collaborate to advocate for more affordable pharmaceutical drug pricing, as this certainly is a driver of inequity,” added Eberly. Racial disparities in death rates from chronic conditions magnified in rural areasHave we made any progress in improving racial health inequities since the early 2000s? Researchers at Harvard Medical School, who published their findings in the Journal of the American College of Cardiology in March 2021, wanted to find out.A large body of evidence has shown that Black Americans experience worse cardiovascular outcomes than White Americans. The research team discovered that hypertension- and diabetes-related death rates are two to three times higher among Black adults than White adults in rural parts of the United States.They researchers found that overall, Black adults have higher death rates from diabetes, hypertension, heart disease, and stroke than White adults and that these racial inequities are magnified in rural areas of the United States.“What’s really concerning is our finding that these striking racial disparities have not meaningfully improved over the last 2 decades,” said lead study author Rishi K. Wadhera, MD.Because rural communities face barriers in accessing health care services, the research team wanted to evaluate whether racial disparities have improved in these communities compared with urban areas. According to Wadhera, racial disparities in death rates due to these conditions persist for several reasons.“Black communities disproportionately face structural and systemic inequities, which lead to a higher burden of comorbid conditions and worse health outcomes,” she said.Examples include poverty, living in disadvantaged areas that have pharmacy deserts and less access to healthy foods, as well as worse access to health care services such as primary and preventtive care. Rural areas, in particular, have experienced a decline in primary care and specialist physicians along with an increase in rural hospital closures.“These inequities may result in lower levels of awareness, treatment, and control for conditions like hypertension and diabetes,” said Wadhera. Have we made any progress in improving racial health inequities since the early 2000s? Researchers at Harvard Medical School, who published their findings in the Journal of the American College of Cardiology in March 2021, wanted to find out. A large body of evidence has shown that Black Americans experience worse cardiovascular outcomes than White Americans. The research team discovered that hypertension- and diabetes-related death rates are two to three times higher among Black adults than White adults in rural parts of the United States. They researchers found that overall, Black adults have higher death rates from diabetes, hypertension, heart disease, and stroke than White adults and that these racial inequities are magnified in rural areas of the United States. “What’s really concerning is our finding that these striking racial disparities have not meaningfully improved over the last 2 decades,” said lead study author Rishi K. Wadhera, MD. Because rural communities face barriers in accessing health care services, the research team wanted to evaluate whether racial disparities have improved in these communities compared with urban areas. According to Wadhera, racial disparities in death rates due to these conditions persist for several reasons. “Black communities disproportionately face structural and systemic inequities, which lead to a higher burden of comorbid conditions and worse health outcomes,” she said. Examples include poverty, living in disadvantaged areas that have pharmacy deserts and less access to healthy foods, as well as worse access to health care services such as primary and preventtive care. Rural areas, in particular, have experienced a decline in primary care and specialist physicians along with an increase in rural hospital closures. “These inequities may result in lower levels of awareness, treatment, and control for conditions like hypertension and diabetes,” said Wadhera. According to the study findings, Black race was independently associated with lower SGLT2 inhibitor use, though Black patients have a disproportionate burden of cardiovascular and kidney disease and experience worse cardiovascular outcomes than White patients. “We know that structural racism is pervasive and there is decreased utilization of many novel cardiovascular therapeutics among marginalized patient groups, especially among Black patients,” said Eberly. In the study, researchers examined data from October 2015 to June 2019 from more than 900,000 diverse, commercially insured patients with type 2 diabetes. Eberly noted that use of a patient cohort with 100% commercial insurance is a concerning bias, however. “Although these findings may not be generalizable to other payer groups, the observed differences may be even greater among those with traditional Medicare or Medicaid or those without health care insurance,” she said. Use of an insurance claims–based database also limited the researchers’ ability to differentiate between prescriptions offered and prescriptions filled. The results are consistent with prior studies, however, which have shown lower use of cardiovascular medications among marginalized patient groups. Eberly noted that the study further supports the need to combat structural inequities in our health care system and to better understand the barriers to prescribing SGLT2 inhibitors. “Strategies to increase the comfort of all providers with prescribing SGLT2 inhibitor therapy will be essential to address inequitable use … for all patients with type 2 diabetes,” she said.