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Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs

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posted on 11.01.2022, 14:20 by Dhruv Mahtta, David J. Ramsey, Michelle T. Lee, Liang Chen, Mahmoud Al Rifai, Julia M. Akeroyd, Elizabeth M. Vaughan, Michael E. Matheny, Karla Rodrigues do Espirito Santo, Sankar D. Navaneethan, Carl J. Lavie, Yochai Birnbaum, Christie M. Ballantyne, Laura A. Petersen, Salim S. Virani
Objective: There is mounting evidence regarding the cardiovascular (CV) benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) and glucagon like peptide-1 receptor agonists (GLP-1RAs) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their utilization.

Research Design and Methods: We used the nationwide Veterans Affairs (VA) healthcare system dataset from January 1, 2020 to December 31, 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1RA and the facility-level variation in their utilization. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1RA in patients with ASCVD and T2DM.

Results: Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received SGLT2i while 8.0% of patients received GLP-1RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10th-90th percentile) facility-level rates were 14.92% (9.31%-22.50%) for SGLT2i and 10.88% (4.44%-17.07%) for GLP-1RA. There was significant facility level variation among SGLT2-Is utilization - MRRunadjusted (95% CI):1.41 (1.35-1.47) and MRRadjusted (95% CI): 1.55 (1.46 – 1.63). Similar facility level variation was observed for utilization of GLP-1 RA – MRRunadjusted (95% CI):1.34 (1.29-1.38) and MRRadjusted (95% CI): 1.78 (1.65 – 1.90).

Conclusions: Overall utilization rates of SGLT2i and GLP-1RA among eligible patients are low with significantly higher residual facility-level variation in utilization of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients.


This work was supported by a Department of Veterans Affairs Health Services Research & Development Service Investigator Initiated Grants (IIR 16–072, IIR 19-069), the Houston VA Health Services Research & Development Center for Innovations grant (CIN13-413), and the NIH/NIDDK (DK110341). 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).The opinions expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs or the US government.