Clinical Research
Utilization Rates of SGLT2 Inhibitors Among Patients With Type 2 Diabetes, Heart Failure, and Atherosclerotic Cardiovascular Disease: Insights From the Department of Veterans Affairs

https://doi.org/10.1016/j.jchf.2023.03.024Get rights and content

Abstract

Background

Multiple clinical trials have demonstrated significant cardiovascular benefit with use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with type 2 diabetes (T2DM) and heart failure (HF) irrespective of ejection fraction. There are limited data evaluating real-world prescription and practice patterns of SGLT2 inhibitors.

Objectives

The authors sought to assess utilization rates and facility-level variation in the use among patients with established atherosclerotic cardiovascular disease (ASCVD), HF, and T2DM using data from the nationwide Veterans Affairs health care system.

Methods

The authors included patients with established ASCVD, HF, and T2DM seen by a primary care provider between January 1, 2020, and December 31, 2020. They assessed the use of SGLT2 inhibitors and the facility-level variation in their use. Facility-level variation was computed using median rate ratios, a measure of likelihood that 2 random facilities differ in use of SGLT2 inhibitors.

Results

Among 105,799 patients with ASCVD, HF, and T2DM across 130 Veterans Affairs facilities, 14.6% received SGLT2 inhibitors. Patients receiving SGLT2 inhibitors were younger men with higher hemoglobin A1c and estimated glomerular filtration rate and were more likely to have HF with reduced ejection fraction and ischemic heart disease. There was significant facility-level variation of SGLT2 inhibitor use, with an adjusted median rate ratio of 1.55 (95% CI: 1.46-1.64), indicating a 55% residual difference in SGLT2 inhibitor use among similar patients with ASCVD, HF, and T2DM receiving care at 2 random facilities.

Conclusions

Utilization rates of SGLT2 inhibitors are low in patients with ASCVD, HF, and T2DM, with high residual facility-level variation. These findings suggest opportunities to optimize SGLT2 inhibitor use to prevent future adverse cardiovascular events.

Section snippets

Study population

This study used data from the nationwide VA administrative and clinical data set. The database comprises veterans aged >18 years with a diagnosis of ASCVD. Patients included in the cohort had at least 1 primary care visit between January 1, 2020, and December 31, 2020, at 130 VA facilities and their associated community-based outpatient clinics. If a patient had multiple primary care visits during the study period, the last primary care visit in the year 2020 was defined as the index visit.

Results

Among the total number of patients with ASCVD in our cohort (n = 1,235,567), we excluded patients with limited life expectancy (n = 32,106). Among these patients, 128,897 patients had ASCVD and concomitant T2DM and HF. We further excluded 23,098 patients with an eGFR of <30 mL/min/1.73 m2 and/or patients with type 1 diabetes. Our primary cohort included 105,799 patients with ASCVD with concomitant T2DM and HF. The overall use of SGLT2 inhibitors within our cohort was 14.6% (SD: 5.8; n = 15,428)

Discussion

In these analyses, we have demonstrated that in patients with high-risk comorbidities associated with a well-established SGLT2 inhibitor benefit (ASCVD, T2DM, and HF), only 15% were treated with SGLT2 inhibitors. Female patients, Black patients, patients with lower eGFR, and patients with PAD or ischemic cerebrovascular disease were less likely to receive SGLT2 inhibitors (Central Illustration). Furthermore, there was significant facility-level variation in the use of SGLT2 inhibitors, which

Conclusions

Our study highlights a very low use of SGLT2 inhibitors in eligible patients with ASCVD, T2DM, and HF with significant facility-level variation. This study serves as a baseline and identifies an opportunity to intensify efforts to improve the utilization of preventive therapies in an extremely high-risk patient phenotype, such as older adults, those other than non-Hispanic White patients, those with lower eGFR, and those with PAD or ischemic cerebrovascular disease. Future studies should

Funding Support and Author Disclosures

This work was supported by a Department of Veterans Affairs (VA) Health Services Research and Development Service Investigator Initiated grants (IIR 16-072, IIR 19-069) and the Houston VA Health Services Research and Development Center for Innovations grant (CIN13-413). Support for VA/Centers for Medicare and Medicaid Services data was provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237

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    G. Michael Felker, MD, served as the Guest Associate Editor for this paper. Barry Greenberg, MD, served as the Guest Editor-in-Chief for this paper.

    The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

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