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Amon S, Aikins M, Haghparast-Bidgoli H, Kretchy IA, Arhinful DK, Baatiema L, Awuah RB, Asah-Ayeh V, Sanuade OA, Kushitor SB, Mensah SK, Kushitor MK, Grijalva-Eternod C, Blandford A, Jennings H, Koram K, Antwi P, Gray E, Fottrell E. Household economic burden of type-2 diabetes and hypertension comorbidity care in urban-poor Ghana: a mixed methods study. BMC Health Serv Res 2024; 24:1028. [PMID: 39232716 PMCID: PMC11375836 DOI: 10.1186/s12913-024-11516-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 08/30/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) predispose households to exorbitant healthcare expenditures in health systems where there is no access to effective financial protection for healthcare. This study assessed the economic burden associated with the rising burden of type-2 diabetes (T2D) and hypertension comorbidity management, and its implications for healthcare seeking in urban Accra. METHODS A convergent parallel mixed-methods study design was used. Quantitative sociodemographic and cost data were collected through survey from a random community-based sample of 120 adults aged 25 years and older and living with comorbid T2D and hypertension in Ga Mashie, Accra, Ghana in November and December 2022. The monthly economic cost of T2D and hypertension comorbidity care was estimated using a descriptive cost-of-illness analysis technique from the perspective of patients. Thirteen focus group discussions (FGDs) were conducted among community members with and without comorbid T2D and hypertension. The FGDs were analysed using deductive and inductive thematic approaches. Findings from the survey and qualitative study were integrated in the discussion. RESULTS Out of a total of 120 respondents who self-reported comorbid T2D and hypertension, 23 (19.2%) provided complete healthcare cost data. The direct cost of managing T2D and hypertension comorbidity constituted almost 94% of the monthly economic cost of care, and the median direct cost of care was US$19.30 (IQR:10.55-118.88). Almost a quarter of the respondents pay for their healthcare through co-payment and insurance jointly, and 42.9% pay out-of-pocket (OOP). Patients with lower socioeconomic status incurred a higher direct cost burden compared to those in the higher socioeconomic bracket. The implications of the high economic burden resulting from self-funding of healthcare were found from the qualitative study to be: 1) poor access to quality healthcare; (2) poor medication adherence; (3) aggravated direct non-medical and indirect cost; and (4) psychosocial support to help cope with the cost burden. CONCLUSION The economic burden associated with healthcare in instances of comorbid T2D and hypertension can significantly impact household budget and cause financial difficulty or impoverishment. Policies targeted at effectively managing NCDs should focus on strengthening a comprehensive and reliable National Health Insurance Scheme coverage for care of chronic conditions.
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Affiliation(s)
- Samuel Amon
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana.
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana.
| | - Moses Aikins
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | | | - Irene Akwo Kretchy
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, University of Ghana, Accra, Ghana
| | - Daniel Kojo Arhinful
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Leonard Baatiema
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
- Center for Tropical Medicine and Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Vida Asah-Ayeh
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Olutobi Adekunle Sanuade
- Department of Population Health Sciences, Division of Health System Innovation and Research, Spencer Fox Eccles School of Medicineat the , University of Utah, Salt Lake City, USA
| | - Sandra Boatemaa Kushitor
- Department of Community Health, Ensign Global College, Kpong, Ghana
- Department of Food Science and Centre for Sustainability Studies, Stellenbosch University, Stellenbosch, South Africa
| | - Sedzro Kojo Mensah
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Mawuli Komla Kushitor
- Institute for Global Health, University College London, London, UK
- Department of Health Policy, Planning and Management (HPPM), Fred N. Binka School of Public Health (HPPM), University of Health and Allied Sciences (UHAS), Ho, Volta Region, Ghana
- London School of Hygiene and Tropical Medicine, London, UK
| | - Carlos Grijalva-Eternod
- Institute for Global Health, University College London, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ann Blandford
- UCL Interaction Centre (UCLIC), University College London, London, UK
| | - Hannah Jennings
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Kwadwo Koram
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Publa Antwi
- Department of Health Sciences, University of York, York, UK
| | - Ethan Gray
- Institute for Global Health, University College London, London, UK
- UCL Interaction Centre (UCLIC), University College London, London, UK
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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Henkin S, Kearing SA, Martinez-Camblor P, Zacharias N, Creager MA, Young MN, Goodney PP, Columbo JA. The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease. Vasc Med 2024:1358863X241237776. [PMID: 38607558 DOI: 10.1177/1358863x241237776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.
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Affiliation(s)
- Stanislav Henkin
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Stephen A Kearing
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Nikolaos Zacharias
- Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mark A Creager
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael N Young
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jesse A Columbo
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Zhao F, Nianogo RA. Evaluating the impact of the Medicaid expansion program on diabetes hospitalization. J Public Health Policy 2024; 45:86-99. [PMID: 38238590 DOI: 10.1057/s41271-023-00463-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 03/09/2024]
Abstract
Diabetes is the most expensive chronic disease in the United States, and hospital inpatient care accounts for 30% of the total medical expenditures. Medical costs for people with limited resources are covered by Medicaid, a joint federal and state program, and its expansion that extent the coverage to those with incomes up to 138% of the federal poverty level. We investigated the impact of Medicaid expansion on diabetes hospitalizations by states and payer, among adults aged 19 to 64 years old, 5 years after the expansion. We found that Medicaid expansion decreased total diabetes hospitalization in most states and a diabetes hospitalization payer mix shifted from private insurance and uninsured to Medicaid. The percentage of diabetes hospitalizations paid by Medicaid increased by 11% (95% CI 7%, 16%), while the percentage paid by private insurance decreased by 6% (95% CI - 8%, - 3%) and the percentage of uninsured diabetes hospitalization decreased by 13% (95% CI - 18%, - 9%).
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Affiliation(s)
- Fan Zhao
- Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA.
| | - Roch A Nianogo
- Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA
- California Center for Population Research (CCPR), Los Angeles, CA, USA
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Chen WH, Li Y, Yang L, Allen JM, Shao H, Donahoo WT, Billelo L, Hu X, Shenkman EA, Bian J, Smith SM, Guo J. Geographic variation and racial disparities in adoption of newer glucose-lowering drugs with cardiovascular benefits among US Medicare beneficiaries with type 2 diabetes. PLoS One 2024; 19:e0297208. [PMID: 38285682 PMCID: PMC10824445 DOI: 10.1371/journal.pone.0297208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/30/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Prior studies have shown disparities in the uptake of cardioprotective newer glucose-lowering drugs (GLDs), including sodium-glucose cotranwsporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1a). This study aimed to characterize geographic variation in the initiation of newer GLDs and the geographic variation in the disparities in initiating these medications. METHODS Using 2017-2018 claims data from a 15% random nationwide sample of Medicare Part D beneficiaries, we identified individuals diagnosed with type 2 diabetes (T2D), who had ≥1 GLD prescriptions, and did not use SGLT2i or GLP1a in the year prior to the index date,1/1/2018. Patients were followed up for a year. The cohort was spatiotemporally linked to Dartmouth hospital-referral regions (HRRs), with each patient assigned to 1 of 306 HRRs. We performed multivariable Poisson regression to estimate adjusted initiation rates, and multivariable logistic regression to assess racial disparities in each HRR. RESULTS Among 795,469 individuals with T2D included in the analyses, the mean (SD) age was 73 (10) y, 53.3% were women, 12.2% were non-Hispanic Black, and 7.2% initiated a newer GLD in the follow-up year. In the adjusted model including clinical factors, compared to non-Hispanic White patients, non-Hispanic Black (initiation rate ratio, IRR [95% CI]: 0.66 [0.64-0.68]), American Indian/Alaska Native (0.74 [0.66-0.82]), Hispanic (0.85 [0.82-0.87]), and Asian/Pacific islander (0.94 [0.89-0.98]) patients were less likely to initiate newer GLDs. Significant geographic variation was observed across HRRs, with an initiation rate spanning 2.7%-13.6%. CONCLUSIONS This study uncovered substantial geographic variation and the racial disparities in initiating newer GLDs.
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Affiliation(s)
- Wei-Han Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Yujia Li
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Lanting Yang
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - John M. Allen
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Hui Shao
- Hubert Department of Global Health, Rollin School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - William T. Donahoo
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Lori Billelo
- Office of Research Affairs, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, United States of America
| | - Xia Hu
- Department of Computer Science, Rice University, Houston, Texas, United States of America
| | - Elizabeth A. Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Steven M. Smith
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
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Waldrop SW, Johnson VR, Stanford FC. Inequalities in the provision of GLP-1 receptor agonists for the treatment of obesity. Nat Med 2024; 30:22-25. [PMID: 38172631 PMCID: PMC10921848 DOI: 10.1038/s41591-023-02669-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
GLP-1 receptor agonists are effective treatments for obesity but are less accessible worldwide than pharmacological treatments for diabetes, reflecting biases and lack of education, and perpetuating health inequalities.
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Affiliation(s)
- Stephanie W Waldrop
- University of Colorado School of Medicine-Anschutz Medical Campus, Department of Pediatrics, Section on Nutrition and Lifestyle Medicine, Nutrition Obesity Research Center at the University of Colorado (CUNORC), Aurora, CO, USA.
| | - Veronica R Johnson
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine, Chicago, IL, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Massachusetts General Hospital Weight Center, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA, USA
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Presley CA, Khodneva Y, Juarez LD, Howell CR, Agne AA, Riggs KR, Huang L, Pisu M, Levitan EB, Cherrington AL. Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019. Prev Chronic Dis 2023; 20:E81. [PMID: 37708338 PMCID: PMC10516203 DOI: 10.5888/pcd20.220332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019. METHODS We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds. RESULTS We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model. CONCLUSION Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.
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Affiliation(s)
- Caroline A Presley
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
- Division of Preventive Medicine, University of Alabama at Birmingham, 1717 11th Ave South, MT-616, Birmingham, AL 35205
| | - Yulia Khodneva
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Lucia D Juarez
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Carrie R Howell
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - April A Agne
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Kevin R Riggs
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Lei Huang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Maria Pisu
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Emily B Levitan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Andrea L Cherrington
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
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Khodneva Y, Levitan EB, Arora P, Presley CA, Oparil S, Cherrington AL. Disparities in Postdischarge Ambulatory Care Follow-Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure. J Am Heart Assoc 2023; 12:e029094. [PMID: 37284763 PMCID: PMC10356027 DOI: 10.1161/jaha.122.029094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/18/2023] [Indexed: 06/08/2023]
Abstract
Background Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7 to 14 days after hospital discharge to improve HF outcomes. We examined postdischarge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care. Methods and Results Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010 to 2019, were included and the claims analyzed for ambulatory care use (any, primary care, cardiology, or endocrinology) within 60 days after discharge using restricted mean survival time regression and negative binomial regression. Among 9859 Medicaid-covered adults with diabetes and first hospitalization for HF (mean age, 53.7 years; SD, 9.2 years; 47.3% Black; 41.8% non-Hispanic White; 10.9% Hispanic/Other [Other included non-White Hispanic, American Indian, Pacific Islander and Asian adults]; 65.4% women, 34.6% men), 26.7% had an ambulatory visit within 0 to 7 days, 15.2% within 8 to 14 days, 31.3% within 15 to 60 days, and 26.8% had no visit; 71% saw a primary care physician and 12% a cardiology physician. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory visit (P<0.0001) or the visit was delayed (by 1.8 days, P=0.0006 and by 2.8 days, P=0.0016, respectively) and were less likely to see a primary care physician than non-Hispanic White adults (adjusted incidence rate ratio, 0.96 [95% CI, 0.91-1.00] and 0.91 [95% CI, 0.89-0.98]; respectively). Conclusions More than half of Medicaid-covered adults with diabetes and HF in Alabama did not receive guideline-concordant postdischarge care. Black and Hispanic/Other adults were less likely to receive recommended postdischarge care for comorbid diabetes and HF.
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Affiliation(s)
- Yulia Khodneva
- Department of Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Emily B. Levitan
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamALUSA
| | - Pankaj Arora
- Department of Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Caroline A. Presley
- Department of Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Suzanne Oparil
- Department of Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
| | - Andrea L. Cherrington
- Department of Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
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Yan Y, Gong Y, Jiang M, Gao Y, Guo S, Huo J, Zhao Z, Li C. Utilization of glucagon-like peptide-1 receptor agonists in children and adolescents in China: a real-world study. Front Endocrinol (Lausanne) 2023; 14:1170127. [PMID: 37383395 PMCID: PMC10293789 DOI: 10.3389/fendo.2023.1170127] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/29/2023] [Indexed: 06/30/2023] Open
Abstract
Background Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been widely used in treating type 2 diabetes mellitus (T2DM) and obesity in adults, but scientific research about the indication in children and adolescents is scarce. The current study aims to explore the prescriptions of GLP-1RAs in children and adolescents in China and to evaluate its rationality. Methods GLP-1RA prescriptions of children and adolescents were retrospectively obtained from the Hospital Prescription Analysis Cooperative Project. The study extracted information on patient's demographic characteristics, monotherapy and combination therapy of GLP-1RAs, and trends in GLP-1RA usage from 2016 to 2021. The rationality of GLP-1RA prescriptions was comprehensively assessed based on the indications approved by China National Medical Products Administration (NMPA), the U.S. Food and Drug Administration (FDA), European Medicines Agency (EMA), Pharmaceuticals and Medical Devices Agency (PMDA), and published randomized controlled trials (RCTs). Results A total of 234 prescriptions from 46 hospitals were included, with a median age of 17 years old. The majority of patients were diagnosed with overweight/obesity or prediabetes/diabetes, accounting for 43.59% and 46.15%, respectively. There were 88 patients on GLP-1RA monotherapy. GLP-1RAs plus metformin was the most common combination therapy (38.89%). 12.39% of patients were found a co-administration with orlistat. The share of overweight/obesity prescriptions increased from 27% in 2016 to 54% in 2021, whereas prediabetes/diabetes prescriptions declined from 55% to 42%. The prescriptions were divided into appropriate and questionable groups according to the diagnosis, and the potentially questionable prescription was related to age (p = 0.017), department visited (p = 0.002), and any hospitalization (p < 0.001). Conclusions This study described the prescribing of GLP-1RAs in children and adolescents. Our findings indicated that the utilization of GLP-1RAs has increased from 2016 to 2021. There was a strong basis for administering GLP-1RAs in overweight/obesity and prediabetes/diabetes, whereas the evidence was insufficient in other conditions. It is crucial to demand robust and sustained efforts to enhance the awareness of the safety of utilization of GLP-1RAs in children and adolescents.
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Affiliation(s)
- Yilong Yan
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Clinical Pharmacology, School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Ying Gong
- Department of Pharmacy, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Meizhu Jiang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Clinical Pharmacology, School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yiming Gao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Clinical Pharmacology, School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Shanshan Guo
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiping Huo
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cao Li
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Essien UR, Singh B, Swabe G, Johnson AE, Eberly LA, Wadhera RK, Breathett K, Vaduganathan M, Magnani JW. Association of Prescription Co-payment With Adherence to Glucagon-Like Peptide-1 Receptor Agonist and Sodium-Glucose Cotransporter-2 Inhibitor Therapies in Patients With Heart Failure and Diabetes. JAMA Netw Open 2023; 6:e2316290. [PMID: 37261826 PMCID: PMC10236237 DOI: 10.1001/jamanetworkopen.2023.16290] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
Importance Type 2 diabetes (T2D) and heart failure (HF) prevalence are rising in the US. Although glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve outcomes for these conditions, high out-of-pocket costs may be associated with reduced medication adherence. Objective To compare 1-year adherence to GLP1-RA and SGLT2i therapies by prescription co-payment level in individuals with T2D and/or HF. Design, Setting, and Participants This retrospective cohort study used deidentified data from Optum Insight's Clinformatics Data Mart Database of enrollees with commercial and Medicare health insurance plans. Individuals aged 18 years or older with T2D and/or HF who had a prescription claim for a GLP1-RA or SLGT2i from January 1, 2014, to September 30, 2020, were included. Exposures Prescription co-payment, categorized as low (<$10), medium ($10 to<$50), and high (≥$50). Main Outcomes and Measures The primary outcome was medication adherence, defined as a proportion of days covered (PDC) of 80% or greater at 1 year. Logistic regression models were used to examine the association between co-payment and adherence, adjusting for patient demographics, medical comorbidities, and socioeconomic factors. Results A total of 94 610 individuals (mean [SD] age, 61.8 [11.4] years; 51 226 [54.1%] male) were prescribed GLP1-RA or SGLT2i therapy. Overall, 39 149 individuals had a claim for a GLP1-RA, of whom 25 557 (65.3%) had a PDC of 80% or greater at 1 year. In fully adjusted models, individuals with a medium (adjusted odds ratio [AOR], 0.62; 95% CI, 0.58-0.67) or high (AOR, 0.47; 95% CI, 0.44-0.51) co-payment were less likely to have a PDC of 80% or greater with a GLP1-RA compared with those with a low co-payment. Overall, 51 072 individuals had a claim for an SGLT2i, of whom 37 339 (73.1%) had a PDC of 80% or greater at 1 year. Individuals with a medium (AOR, 0.67; 95% CI, 0.63-0.72) or high (AOR, 0.68; 95% CI, 0.63-0.72) co-payment were less likely to have a PDC of 80% or greater with an SGLT2i compared with those with a low co-payment. Conclusions and Relevance In this cohort study of individuals with T2D and/or HF, 1-year adherence to GLP1-RA or SGLT2i therapies was highest among individuals with a low co-payment. Improving adherence to guideline-based therapies may require interventions that reduce out-of-pocket prescription costs.
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Affiliation(s)
- Utibe R. Essien
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Balvindar Singh
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gretchen Swabe
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amber E. Johnson
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lauren A. Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jared W. Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Department of Medicine, Pittsburgh, Pennsylvania
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10
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Nanna MG, Kolkailah AA, Page C, Peterson ED, Navar AM. Use of Sodium-Glucose Cotransporter 2 Inhibitors and Glucagonlike Peptide-1 Receptor Agonists in Patients With Diabetes and Cardiovascular Disease in Community Practice. JAMA Cardiol 2023; 8:89-95. [PMID: 36322056 PMCID: PMC9631221 DOI: 10.1001/jamacardio.2022.3839] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
Importance Recent national guidelines recommend sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD); yet, there are limited data on the use of these agents in contemporary community practice. Objective To evaluate the use of SGLT2i and GLP-1 RA in adults with T2D and ASCVD across a diverse sample of health care systems in the US. Design, Setting, and Participants This multicenter, retrospective cohort study used electronic health record data from 88 US health care systems participating in Cerner Real World Data between January 2018 to March 2021. Adults with ASCVD and T2D taking at least 1 glucose-lowering medication, had end-stage kidney disease, or had stage 5 chronic kidney disease were excluded. Main Outcomes and Measures Treatment with SGLT2i or GLP-1 RA. Results A total of 321 304 patients were identified with T2D and ASCVD ASCVD (130 280 female [40.5%]; median [IQR] age, 70.9 [62.9-78.0] years) who were potentially eligible for SGLT2i and/or GLP-1 RA, including 37 754 Black individuals (11.8%), 51 522 Hispanic individuals (16.0%), and 256 008 White individuals (11.8%). From January 2018 to March 2021, the use of SGLT2i increased from 5.8% (11 285 of 194 264) to 12.9% (11 058 of 85 956), GLP-1 RA increased from 6.9% (13 402 of 194 264) to 13.8% (11 901 of 85 956), and use of either agent increased from 11.4% (22 069 of 194 264) to 23.2% (19 909 of 85 956). Those taking an SGLT2i or GLP-1 RA were younger, less frequently hospitalized in the year prior, and more likely to be taking additional secondary prevention medications. Treated and nontreated populations were similar in terms of race, ethnicity, and outpatient health care utilization. Sulfonylureas and dipeptidyl peptidase 4 inhibitors remained more commonly used than SGLT2i or GLP-1 RA through 2021. Conclusions and Relevance In this study, uptake of SGLT2i and GLP-1 RA in adults with T2D and ASCVD increased modestly after guideline recommendations, although less than a quarter of persons with ASCVD and T2D receiving medical therapy were taking either. Further efforts are necessary to maximize the potential population benefit of these therapies in this high-risk population.
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Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Courtney Page
- Duke Clinical Research Institute, Durham, North Carolina
| | - Eric D. Peterson
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Ann Marie Navar
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
- Deputy Editor of Diversity, Equity, and Inclusion, JAMA Cardiology
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11
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Tekin Z, Saygili M. The Association Between Medicaid Expansion and Diabetic Ketoacidosis Hospitalizations. Cureus 2022; 14:e30631. [PMID: 36426322 PMCID: PMC9682969 DOI: 10.7759/cureus.30631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 06/16/2023] Open
Abstract
Background and objective Diabetic ketoacidosis (DKA) is a potentially fatal complication of uncontrolled diabetes and remains a significant source of morbidity and mortality even though it is considered preventable. Diabetes is a chronic illness that requires constant monitoring and regular check-ups. Delaying or foregoing necessary diabetes care due to a lack of health insurance can result in severe complications. The Affordable Care Act (ACA) Medicaid expansion is intended to increase access to healthcare and improve health outcomes. This study aimed to examine the relationship between the ACA Medicaid expansion and hospitalizations with DKA. Methods This retrospective cross-sectional study used discharge records from 2010 to 2017 for hospitals in Texarkana, located on the border of Texas and Arkansas. The study employed a difference-in-differences method. Patients from Arkansas, which expanded Medicaid in 2014, constituted the treatment group, while those from Texas, which did not adopt the expansion, were the control group. A triple difference methodology was used to compare the impact of the expansion on patients with different socioeconomic backgrounds. The main outcome measure was DKA per 1000 discharges. Results A total of 89,184 inpatient discharges from Texarkana hospitals were analyzed; 43,286 patients were from Arkansas (48.54%) and 45,898 (51.46%) were from Texas. Even though DKA cases increased from pre-expansion (2010-2013) to post-expansion (2014-2017) period among patients from Arkansas (by a mean of 4.33) and Texas (by a mean of 8.28), the increase was milder among Arkansas patients with an adjusted decrease of 4.17 per 1000 discharges (95% CI: -5.04 to -3.31; p<0.001), implying a 42% lower risk of hospitalizations with DKA compared to the baseline averages. The triple difference analysis suggested that the decrease in incidences was more pronounced for patients from low-income areas with an adjusted decrease of 13.47 per 1000 discharges (95% CI: -22.45 to -4.49; p=0.003). Conclusions Based on our findings, Medicaid expansion decreases hospitalizations with DKA, presumably due to better monitoring and care of diabetes made possible by increasing access to healthcare among individuals with low incomes.
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Affiliation(s)
- Zehra Tekin
- Endocrinology, Diabetes and Metabolism, Christus Trinity Clinic, Tyler, USA
| | - Meryem Saygili
- Social Sciences/Economics, The University of Texas at Tyler, Tyler, USA
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12
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Oseran AS, Sun T, Wadhera RK. Health Care Access and Management of Cardiovascular Risk Factors Among Working-Age Adults With Low Income by State Medicaid Expansion Status. JAMA Cardiol 2022; 7:708-714. [PMID: 35648424 DOI: 10.1001/jamacardio.2022.1282] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Medicaid expansion led to gains in insurance coverage among working-age adults with low income. To date, the extent to which disparities in access and cardiovascular care persist for this population in Medicaid nonexpansion and expansion states is unknown. Objective To compare insurance coverage, health care access, and cardiovascular risk factor management between working-age adults (age 18-64 years) with low income in Medicaid nonexpansion and expansion states and between uninsured and insured adults in these states. Design, Setting, and Participants This cross-sectional study analyzed data on adults aged 18 to 64 years with low income from the Behavioral Risk Factor Surveillance System from January 1 to December 31, 2019. Exposures State Medicaid expansion and insurance status. Main Outcomes and Measures The main outcomes were health care access and monitoring and treatment of cardiovascular risk factors. The estimated adjusted risk difference (RD) in outcomes was estimated to compare adults in Medicaid nonexpansion and expansion states and uninsured and insured individuals in nonexpansion and expansion states. Results The weighted study population consisted of 28 028 451 working-age adults with low income, including 10 094 994 (36.0%) in Medicaid nonexpansion states (63.4% female) and 17 933 457 (64.0%) in expansion states (59.2% female). Adults in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2%-44.7%] vs 23.8% [95% CI, 22.8%-24.8%]), were less likely to have a usual source of care (55.4% [95% CI, 53.1%-57.6%] vs 65.4% [95% CI, 64.3%-66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]) or a recent examination (78.9% [95% CI, 77.0%-80.9%] vs 84.4% [95% CI, 83.5%-85.2%]; RD, -6.2% [95% CI, -8.4% to -4.0%]), and were more likely to have deferred care owing to cost (36.1% [95% CI, 34.0%-38.2%] vs 21.8% [95% CI, 20.9%-22.8%]; RD, 14.2% [95% CI, 11.9%-16.6%]) than were those in expansion states. There were no significant differences in cardiovascular risk factor management between these groups. In nonexpansion states, uninsured adults had significantly worse access to care across these measures and were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7%-77.4%] vs 93.7%; [95% CI, 92.4%-95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1c (55.2% [95% CI, 40.0%-72.5%] vs 88.5% [95% CI, 79.2%-97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]) levels or to receive treatment for hypertension (49.4% [95% CI, 43.3%-55.6%] vs 74.7% [95% CI, 71.5%-78.0%]; RD, -16.3% [95% CI, -23.2% to -9.4%]) and hyperlipidemia (30.2% [95% CI, 23.5%-36.8%] vs 58.7% [95% CI, 53.9%-63.5%]; RD, -19.3% [95% CI, -27.9% to -10.7%]) compared with insured adults. These patterns were similar for uninsured and insured adults in expansion states. Conclusions and Relevance In this study, working-age adults with low income in Medicaid nonexpansion states experienced higher uninsurance rates and worse access to care than did those in expansion states; however, cardiovascular risk factor management was similar and treatment rates were low. In nonexpansion states, uninsured adults were less likely to receive appropriate cardiovascular risk factor management compared with insured adults.
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Affiliation(s)
- Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Cardiology, Massachusetts General Hospital, Boston
| | - Tianyu Sun
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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13
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Nelson AJ, O’Brien EC, Kaltenbach LA, Green JB, Lopes RD, Morse CG, Al-Khalidi HR, Aroda VR, Cavender MA, Gaynor T, Kirk JK, Lingvay I, Magwire ML, McGuire DK, Pak J, Pop-Busui R, Richardson CR, Senyucel C, Kelsey MD, Pagidipati NJ, Granger CB. Use of Lipid-, Blood Pressure-, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2022; 5:e2148030. [PMID: 35175345 PMCID: PMC8855234 DOI: 10.1001/jamanetworkopen.2021.48030] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Based on contemporary estimates in the US, evidence-based therapies for cardiovascular risk reduction are generally underused among patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To determine the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (ie, coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1 and December 31, 2018. Data were analyzed from September 2020 until January 2021. EXPOSURES One or more health care encounters in 2018. MAIN OUTCOMES AND MEASURES Patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA). RESULTS The overall cohort included 324 706 patients, with a mean (SD) age of 68.1 (12.2) years and 144 169 (44.4%) women and 180 537 (55.6%) men. A total of 59 124 patients (18.2% ) were Black, and 41 470 patients (12.8%) were Latinx. Among 205 885 patients with specialized visit data from the prior year, 17 971 patients (8.7%) visited an endocrinologist, 54 330 patients (26.4%) visited a cardiologist, and 154 078 patients (74.8%) visited a primary care physician. Overall, 190 277 patients (58.6%) were prescribed a statin, but only 88 426 patients (26.8%) were prescribed a high-intensity statin; 147 762 patients (45.5%) were prescribed an ACEI or ARB, 12 724 patients (3.9%) were prescribed a GLP-1RA, and 8989 patients (2.8%) were prescribed an SGLT2I. Overall, 14 918 patients (4.6%) were prescribed all 3 classes of therapies, and 138 173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs 73.0% [95% CI, 72.8%-73.3%] of patients) and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs 26.4% [95% CI, 26.2%-26.6%] of patients). CONCLUSIONS AND RELEVANCE In this large cohort of US patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all 3 evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA. These findings suggest that multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and facilitate their optimal use.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Caryn G. Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | | | | | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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14
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Elhussein A, Anderson A, Bancks MP, Coday M, Knowler WC, Peters A, Vaughan EM, Maruthur NM, Clark JM, Pilla S. Racial/ethnic and socioeconomic disparities in the use of newer diabetes medications in the Look AHEAD study. LANCET REGIONAL HEALTH. AMERICAS 2022; 6:100111. [PMID: 35291207 PMCID: PMC8920048 DOI: 10.1016/j.lana.2021.100111] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022]
Abstract
Background Among patients with type 2 diabetes, minority racial/ethnic groups have a higher burden of cardiovascular disease, chronic kidney disease, and hypoglycaemia. These groups may especially benefit from newer diabetes medication classes, but high cost may limit access. We examined the association of race/ethnicity with the initiation of newer diabetes medications (GLP-1 receptor agonists, DPP-4 inhibitors, SGLT-2 inhibitors). Methods We conducted a secondary analysis of the Look AHEAD (Action for Health in Diabetes) trial including participants with at least one study visit after April 28, 2005. Cox proportional hazards models were used to estimate the association between race/ethnicity and socioeconomic factors with time to initiation of any newer diabetes medication from April 2005 to February 2020. Models were adjusted for demographic and clinical characteristics. Findings Among 4,892 participants, 63.6%, 15.7%, 12.6%, 5.2%, and 2.9% were White, Black, Hispanic, American Indian or Alaskan Native (AI/AN), or other race/ethnicity, respectively. During a median follow-up of 8.3 years, 2,180 (45.2%) participants were initiated on newer diabetes medications. Race/ethnicity was associated with newer diabetes medication initiation (p=.019). Specifically, initiation was lower among Black (HR 0.81, 95% CI 0.70 -0.94) and AI/AN participants (HR 0.51, 95% CI 0.26-0.99). Yearly family income was inversely associated with initiation of newer diabetes medications (HR 0.78, 95% CI 0.62-0.98) comparing the lowest and highest income groups. Findings were mostly driven by GLP-1 receptor agonists. Interpretation These findings provide evidence of racial/ethnic disparities in the initiation of newer diabetes medications, independent of socioeconomic factors, which may contribute to worse health outcomes.
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Affiliation(s)
- Ahmed Elhussein
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrea Anderson
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael P Bancks
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mace Coday
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - William C Knowler
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, USA
| | - Anne Peters
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Nisa M. Maruthur
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD, USA
| | - Jeanne M Clark
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD, USA
| | - Scott Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD, USA
| | - The Look AHEAD Research Group
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD, USA
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15
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Sumarsono A, Lalani H, Segar MW, Rao S, Vaduganathan M, Wadhera RK, Das SR, Navar AM, Fonarow GC, Pandey A. Association of Medicaid Expansion With Rates of Utilization of Cardiovascular Therapies Among Medicaid Beneficiaries Between 2011 and 2018. Circ Cardiovasc Qual Outcomes 2021; 14:e007492. [PMID: 33161766 PMCID: PMC8261855 DOI: 10.1161/circoutcomes.120.007492] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Affordable Care Act expanded Medicaid eligibility allowing low-income individuals greater access to health care. However, the uptake of state Medicaid expansion has been variable. It remains unclear how the Medicaid expansion was associated with the temporal trends in use of evidence-based cardiovascular drugs. METHODS We used the publicly available Medicaid Drug Utilization and Current Population Survey to extract filled prescription rates per 1000 Medicaid beneficiaries of statins, antihypertensives, P2Y12 inhibitors, and direct oral anticoagulants. We defined expander states as those who expanded Medicaid on or before January 1, 2014, and nonexpander states as those who had not expanded by December 31, 2018. Difference-in-differences (DID) analyses were performed to compare the association of the Medicaid expansion with per-capita cardiovascular drug prescription rates in expander versus nonexpander states. RESULTS Between 2011 and 2018, the total number of prescriptions among all Medicaid beneficiaries increased, with gains of 89.7% in statins (11.0 to 20.8 million), 76% in antihypertensives (35.3 to 62.2 million), and 37% in P2Y12 inhibitors (1.7 to 2.3 million). Medicaid expansion was associated with significantly greater increases in quarterly prescriptions (per 1000 Medicaid beneficiaries) of statins (DID estimate [95% CI]: 22.5 [16.5-28.6], P<0.001), antihypertensives (DID estimate [95% CI]: 63.2 [47.3-79.1], P<0.001), and P2Y12 inhibitors (DID estimate [95% CI]: 1.7 [1.2-2.2], P<0.001). Between 2013 and 2018, >75% of the expander states had increases in prescription rates of both statins and antihypertensives. In contrast, 44% of nonexpander states saw declines in statins and antihypertensives. The Medicaid expansion was not associated with higher direct oral anticoagulants prescription rates (DID estimate [95% CI] 0.9 [-0.3 to 2.1], P=0.142). CONCLUSIONS The 2014 Medicaid expansion was associated with a significant increase in per-capita utilization of cardiovascular prescription drugs among Medicaid beneficiaries. These gains in utilization may contribute to long-term cardiovascular benefits to lower-income and previously underinsured populations.
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Affiliation(s)
- Andrew Sumarsono
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Division of Hospital Medicine, Parkland Memorial Hospital, Dallas, TX
| | - Hussain Lalani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew W. Segar
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shreya Rao
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sandeep R. Das
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ann Marie Navar
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gregg C. Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
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