TY - JOUR
T1 - Predictors, Disparities, and Facility-Level Variation
T2 - SGLT2 Inhibitor Prescription Among US Veterans With CKD
AU - Gregg, L. Parker
AU - Ramsey, David J.
AU - Akeroyd, Julia M.
AU - Jafry, Shehrezade A.
AU - Matheny, Michael E.
AU - Virani, Salim S.
AU - Navaneethan, Sankar D.
N1 - Funding Information:
L. Parker Gregg, MD, MSCS, David J. Ramsey, PhD, Julia M. Akeroyd, MPH, Shehrezade A. Jafry, BA, Michael E. Matheny, MD, MS, MPH, Salim S. Virani, MD, PhD, and Sankar D. Navaneethan, MD, MS, MPH. Research idea and study design: DJR, MEM, SSV, SDN; data acquisition: DJR, JMA SSV, SDN; data analysis/interpretation: LPG, DJR, JMA, SAJ, MEM, SSV, SDN; statistical analysis: DJR; supervision or mentorship: SSV, SDN. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual's own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, including documentation in the literature if appropriate. This work was supported by Department of Veterans Affairs Health Service Research & Development Service Investigator Initiated Grants (IIR 16-072, IIR 19-069), and the Houston VA Health Services Research & Development Center for Innovations grant (CIN13-413), and NIH/NHLBI grant K24 HL161414 (SDN). Support for VA/CMS data provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). Dr Gregg is supported by a VA Clinical Sciences Research & Development Career Development Award (IK2CX002368). Dr Virani is supported by research grants from the Department of Veterans Affairs, NIH, and the Tahir and Jooma Family. The funders did not have a role in study design, data collection, analysis, reporting or the decision to submit for publication. Dr Navaneethan reports receiving personal fees from ACI Clinical, Astra Zeneca (Data Safety Monitoring Board) Bayer, Boehringer Ingelheim, Eli Lilly and Co, Vertex, and Vifor; receiving grants from Keryx; and receiving research funding from the Department of Veterans Affairs Health Services Research & Development outside the submitted work. Dr Virani has received honoraria from the American College of Cardiology in his role as the Associate Editor for Innovations, acc.org. The remaining authors declare that they have no relevant financial interests. Dr Gregg serves as an editorial fellow for the Journal of the American Society of Nephrology. The interpretation and reporting of these data are the responsibility of the authors and in no way should be viewed as official policy or interpretation of the Department of Veterans Affairs or the US government. The opinions expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, NIH or the US government. Received July 18, 2022. Evaluated by 4 external peer reviewers and a statistician, with editorial input from an Acting Editor-in-Chief (Editorial Board Member Amy K. Mottl, MD, MPH). Accepted in revised form November 27, 2022. The involvement of an Acting Editor-in-Chief to handle the peer-review and decision-making processes was to comply with AJKD's procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies.
Funding Information:
Dr Navaneethan reports receiving personal fees from ACI Clinical, Astra Zeneca (Data Safety Monitoring Board) Bayer, Boehringer Ingelheim, Eli Lilly and Co, Vertex, and Vifor; receiving grants from Keryx ; and receiving research funding from the Department of Veterans Affairs Health Services Research & Development outside the submitted work. Dr Virani has received honoraria from the American College of Cardiology in his role as the Associate Editor for Innovations, acc.org. The remaining authors declare that they have no relevant financial interests.
Funding Information:
This work was supported by Department of Veterans Affairs Health Service Research & Development Service Investigator Initiated Grants ( IIR 16-072 , IIR 19-069 ), and the Houston VA Health Services Research & Development Center for Innovations grant ( CIN13-413 ), and NIH / NHLBI grant K24 HL161414 (SDN). Support for VA/CMS data provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). Dr Gregg is supported by a VA Clinical Sciences Research & Development Career Development Award ( IK2CX002368 ). Dr Virani is supported by research grants from the Department of Veterans Affairs , NIH , and the Tahir and Jooma Family. The funders did not have a role in study design, data collection, analysis, reporting or the decision to submit for publication.
Publisher Copyright:
© 2023
PY - 2023/7
Y1 - 2023/7
N2 - Rationale & Objective: Sodium/glucose cotransporter 2 (SGLT2) inhibitors are recommended for type 2 diabetes mellitus (T2DM) in patients with chronic kidney disease (CKD) or atherosclerotic cardiovascular disease (ASCVD). We evaluated factors associated with SGLT2 inhibitor prescription, disparities by race and sex, and facility-level variation in prescription patterns. Study Design: Retrospective cohort. Setting & Participants: A national sample of US veterans with comorbid T2DM, CKD, and ASCVD with a primary care visit between January 1 and December 31, 2020. Exposure: Race, sex, and individual Veterans Affairs (VA) location. Outcome: SGLT2 inhibitor prescription. Analytical Approach: Multivariable logistic regression assessed associations of race and sex with SGLT2 inhibitor prescription. Facility-level variation in SGLT2i prescription was quantified by median rate ratios (MRR), which express the likelihood that 2 randomly selected facilities differ in their use of SGLT2 inhibitor among similar patients. Results: Of 174,443 patients with CKD, T2DM, and ASCVD, 20,024 (11.5%) were prescribed an SGLT2 inhibitor. Lower odds of SGLT2 inhibitor prescription were seen in Black or African American patients compared with White patients (OR, 0.87 [95% CI, 0.83-0.91]) and among women compared with men (OR, 0.59 [95% CI 0.52-0.67]). The adjusted MRR for SGLT2 inhibitor prescription was 1.58 (95% CI 1.48-1.67) in the total cohort, indicating an unexplained 58% variation in treatment between VA facilities, independent of patient and facility characteristics. Facility-level variation was evaluated among Black or African American patients (MRR, 1.55 [95% CI 1.41-1.68]), White patients (MRR, 1.57 [95% CI 1.47-1.66]), women (MRR, 1.40 [95% CI 1.28-1.51]), and men (MRR, 1.57 [95% CI 1.48-1.67]). Limitations: Albuminuria was not assessed. Conclusions: Prescription for SGLT2 inhibitors was low among likely eligible patients, with evident disparities by sex and race and between individual VA facilities. Efforts are needed to study and address the reasons for these disparities to improve equitable adoption of these important medications.
AB - Rationale & Objective: Sodium/glucose cotransporter 2 (SGLT2) inhibitors are recommended for type 2 diabetes mellitus (T2DM) in patients with chronic kidney disease (CKD) or atherosclerotic cardiovascular disease (ASCVD). We evaluated factors associated with SGLT2 inhibitor prescription, disparities by race and sex, and facility-level variation in prescription patterns. Study Design: Retrospective cohort. Setting & Participants: A national sample of US veterans with comorbid T2DM, CKD, and ASCVD with a primary care visit between January 1 and December 31, 2020. Exposure: Race, sex, and individual Veterans Affairs (VA) location. Outcome: SGLT2 inhibitor prescription. Analytical Approach: Multivariable logistic regression assessed associations of race and sex with SGLT2 inhibitor prescription. Facility-level variation in SGLT2i prescription was quantified by median rate ratios (MRR), which express the likelihood that 2 randomly selected facilities differ in their use of SGLT2 inhibitor among similar patients. Results: Of 174,443 patients with CKD, T2DM, and ASCVD, 20,024 (11.5%) were prescribed an SGLT2 inhibitor. Lower odds of SGLT2 inhibitor prescription were seen in Black or African American patients compared with White patients (OR, 0.87 [95% CI, 0.83-0.91]) and among women compared with men (OR, 0.59 [95% CI 0.52-0.67]). The adjusted MRR for SGLT2 inhibitor prescription was 1.58 (95% CI 1.48-1.67) in the total cohort, indicating an unexplained 58% variation in treatment between VA facilities, independent of patient and facility characteristics. Facility-level variation was evaluated among Black or African American patients (MRR, 1.55 [95% CI 1.41-1.68]), White patients (MRR, 1.57 [95% CI 1.47-1.66]), women (MRR, 1.40 [95% CI 1.28-1.51]), and men (MRR, 1.57 [95% CI 1.48-1.67]). Limitations: Albuminuria was not assessed. Conclusions: Prescription for SGLT2 inhibitors was low among likely eligible patients, with evident disparities by sex and race and between individual VA facilities. Efforts are needed to study and address the reasons for these disparities to improve equitable adoption of these important medications.
KW - Atherosclerotic cardiovascular disease
KW - SGLT2 inhibitors
KW - chronic kidney disease
KW - diabetes mellitus
UR - http://www.scopus.com/inward/record.url?scp=85150411685&partnerID=8YFLogxK
U2 - 10.1053/j.ajkd.2022.11.017
DO - 10.1053/j.ajkd.2022.11.017
M3 - Article
C2 - 36702340
AN - SCOPUS:85150411685
SN - 0272-6386
VL - 82
SP - 53-62.e1
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
IS - 1
ER -
