Racial, Ethnic, and Socioeconomic Inequities in Glucagon-Like Peptide-1 Receptor Agonist Use Among Patients With Diabetes in the US

Question Are there inequities in glucagon-like peptide-1 receptor agonist (GLP-1 RA) use based on race, ethnicity, sex, and socioeconomic status among patients with diabetes in the US? Findings This 5-year cohort study of 1 180 260 commercially insured patients with diabetes in the US found that GLP-1 RA use increased but use remained low. Lower rates of GLP-1 RA use were found among Asian, Black, and Hispanic individuals and among those with lower household income; results were similar among patients with diabetes who also had cardiovascular disease. Meaning The findings of this cohort study suggest that racial, ethnic, and socioeconomic inequities are present in access to GLP-1 RA, a medication with established benefits for improved cardiovascular outcomes in patients with diabetes. Importance Randomized clinical trials have shown that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) cause significant weight loss and reduce cardiovascular events in patients with type 2 diabetes (T2D). Black patients have a disproportionate burden of obesity and cardiovascular disease and have a higher rate of cardiovascular-related mortality. Racial and ethnic disparities in health outcomes are largely attributable to the pervasiveness of structural racism, and patients who are marginalized by racism have less access to novel therapeutics. Objectives To evaluate GLP-1 RA uptake among a commercially insured population of patients with T2D; identify associations of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use; and specifically examine its use among the subgroup of patients with atherosclerotic cardiovascular disease (ASCVD) because of the known benefit of GLP-1 RA use for this population. Design, Setting, and Participants This was a retrospective cohort analysis using data from OptumInsight Clinformatics Data Mart of commercially insured adult patients with T2D (with or without ASCVD) in the US. Data from October 1, 2015, to June 31, 2019, were included, and the analyses were performed in July 2020. We estimated multivariable logistic regression models to identify the association of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use. Main Outcome and Measure A prescription for a GLP-1 RA. Results Of the 1 180 260 patients with T2D (median [IQR] age, 69 [59-76] years; 50.3% female; 57.7% White), 90 934 (7.7%) were treated with GLP-1 RA during the study period. From 2015 to 2019, the percentage of T2D patients treated with an GLP-1 RA increased from 3.2% to 10.7%. Among patients with T2D and ASCVD, use also increased but remained low (2.8%-9.4%). In multivariable analyses, lower rates of GLP-1 RA use were found among Asian (aOR, 0.59; 95% CI, 0.56-0.62), Black (adjusted odds ratio [aOR] 0.81; 95% CI, 0.79-0.83), and Hispanic (aOR, 0.91; 95% CI, 0.88-0.93) patients with T2D. Female sex (aOR, 1.22; 95% CI, 1.20-1.24) and higher zip code-linked median household incomes (>$100 000 [OR, 1.13; 95% CI, 1.11-1.16] and $50 000-$99 999 [OR, 1.07; 95% CI, 1.05-1.09] vs <$50 000) were associated with higher GLP-1 RA use. These results were similar to those found among patients with ASCVD. Conclusions and Relevance In this cohort study of US patients with T2D, GLP-1 RA use increased, but remained low overall for treatment of T2D, particularly among patients with ASCVD who are likely to derive the most benefit. Asian, Black, and Hispanic patients and those with low income were less likely to receive treatment with a GLP-1 RA. Strategies to lower barriers to GLP-1 RA use, such as lower cost, are needed to prevent the widening of well-documented inequities in cardiovascular disease outcomes in the US. This cohort study examines the racial, ethnic, sex, and socioeconomic inequities associated with use of glucagon-like peptide-1 receptor agonists in US patients with type 2 diabetes.

Automated summary

This study highlights the racial, ethnic, sex, and socioeconomic inequities related to the use of glucagon-like peptide-1 receptor agonists among patients with type 2 diabetes in the US. Despite an increase in GLP-1 RA use, disparities persist with lower usage rates among Asian, Black, Hispanic, and low-income patients. Lowering barriers to GLP-1 RA use is crucial to address documented inequities in cardiovascular outcomes in the US.