Retrospective Cohort Review of Pharmacists' Impact on Disparities in Care in the Management of Type 2 Diabetes with Glucagon-Like peptide -1 Agonists and Sodium-Glucose Co-transporter 2 Inhibitors

Retrospective Cohort Review of Pharmacists' Impact on Disparities in Care in the Management of Type 2 Diabetes with Glucagon-Like peptide -1 Agonists and Sodium-Glucose Co-transporter 2 Inhibitors
Debesai Hailemicael, PharmD, Minnesota Community Care

Background: According to the Look AHEAD trial, obesity, cardiovascular disease, and chronic kidney disease disproportionately affect Black patients. Therefore, guideline-directed prescribing practices would indicate that more Glucagon-Like Peptide-1 (GLP-1) agonists and Sodium-Glucose Co-transporter 2 (SGLT-2) inhibitors should be prescribed in this patient population. However, secondary analyses of the trial reported that GLP-1 agonists and SGLT-2 inhibitors were prescribed at a significantly lower rate during treatment initiation in Black patients than in White patients. Pharmacists' knowledge of patient saving programs, copay cards, discounts, and medication formularies could provide a unique opportunity to lower racial disparities in prescribing GLP-1 agonists and SGLT-2 inhibitors. 

Objective: This study assessed if there was a disparity in prescribing of GLP-1 agonists and SGLT-2 inhibitors between White patients and Black patients in a primary care setting. 

Study Design: This study was a single-center, retrospective chart review cohort study that enrolled patients seen between June 1, 2018 and May 30, 2020 for the diagnosis of type 2 diabetes in a primary care setting. The study included a pharmacist comanaged group and a provider managed group. The patients in the pharmacist comanaged group completed at least one visit with a provider and one visit with a pharmacist during the study period. The primary outcome was the difference in prescribing rates of GLP-1 agonists and SGLT-2 inhibitors between White and Black patients. The secondary outcomes were prescribing rate differences for both groups based on insurance status, serious mental illness, and the overall impact of these variables on prescribing rates in both groups combined. The overall impact assessed if pharmacist involvement made a difference in prescribing the two classes of medications.

Results: No significant difference was seen for the study's primary outcome between the races within the pharmacist comanaged groups (White 64%, Black 62%, Hispanic 58%, and other races 64% (P=0.77)). In the provider managed group, the prescribing rates of the diabetic agents between the races were: White 14%, Black 11%, Hispanic 15%, and other races 32%. Insurance status was significantly associated with prescribing a GLP-1 agonist or SGLT-2 inhibitor in the pharmacist managed group. 

Sixty-four patients (43%) who did not have insurance were prescribed a GLP-1 agonist compared with 384 patients (56%) with insurance (P=0.005). Seventy-eight patients (52%) who did not have insurance were prescribed either a GLP-1 agonist or SGLT-2 inhibitor compared with 442 patients (64%) with insurance (P=0.007). The study found no statistical significance in prescribing in the provider managed group based on insurance status.

In the pharmacist comanaged group, GLP-1 agonists were prescribed at a higher rate (n=111, 61%) in patients with serious mental illness compared to those without (n=337, 51%; P=0.019). Moreover, more than two-thirds of those with serious mental illness (n=125, 69%) were prescribed either of the two agents compared with those without a mental illness (n=395, 60%). No statistical difference was shown in prescribing rates in patients with serious mental illness in the provider managed group. 

Overall, when only a provider was involved in diabetes care, it was a predictor of not

being prescribed either a GLP-1 agonist or SGLT-2 inhibitor (odds ratio (OR)=0.096; P<0.001). Having insurance was also a predictor of being prescribed either agent (OR=1.592; P=0.006). Race and serious mental illness did not reach significance for the prescribing of either agent (OR=1.14; P=0.128 and OR=1.209; P=0.07, respectively)

Conclusion: The limitations of the study include selection and recall bias due to the study being retrospective, weak external validity due to being a single-centered study, and confounding variables that were not identified and accounted for.  Race did not contribute to the prescribing rate differences of GLP-1 agonists and SGLT-2 inhibitors in both groups. Involving pharmacists in diabetes care and having insurance positively affected the prescribing of the two agents. 

Key points: GLP-1 agonists and SGLT-2 inhibitors are drugs of choice in patients with diabetes, obesity, cardiovascular disease, and chronic kidney disease. Involving pharmacists in the care of patients with diabetes and having insurance coverage can help increase prescribing rates of GLP-1 agonists and SGLT-2 inhibitors in Black patients when indicated.

References:

  1. Howell C, Schmelz A, Albertson S, et al. Retrospective, cohort review of pharmacists’ impact on disparities in care in the management of type 2 diabetes with glucagon-like peptide-1 agonists and sodium glucose co-transporter 2 inhibitors. JACCP: Journal of the American College of Clinical Pharmacy. n/a(n/a). doi:10.1002/jac5.1626.
  2. Elhussein A, Bancks M, Knowler WC, et al. 37-OR: Racial and socioeconomic disparities in the use of newer classes of diabetes medications. Diabetes. 2020;69(Supplement_1):37-OR. doi:10.2337/db20-37-OR.
  3. Artiga S, Hill L, Orgera K, Damico A. Health coverage by race and ethnicity, 2010-2019. KFF. Published July 16, 2021. Accessed May 18, 2022. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-c...