Gaps in Evidence‐Based Therapy Use in Insured Patients in the United States With Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease

Abstract

Background Evidence‐based therapies are generally underused for cardiovascular risk reduction; however, less is known about contemporary patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. Methods and Results Pharmacy and medical claims data from within Anthem were queried for patients with established atherosclerotic cardiovascular disease and type 2 diabetes mellitus. Using an index date of April 18, 2018, we evaluated the proportion of patients with a prescription claim for any of the 3 evidence‐based therapies on, or covering, the index date ±30 days: high‐intensity statin, angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker, and sodium glucose cotransporter‐2 inhibitor or glucagon‐like peptide‐1 receptor agonist. The potential benefit of achieving 100% adoption of all 3 evidence‐based therapies was simulated using pooled treatment estimates from clinical trials. Of the 155 958 patients in the sample, 24.7% were using a high‐intensity statin, 53.1% were using an angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker, and 9.9% were using either an sodium glucose cotransporter‐2 inhibitor or glucagon‐like peptide‐1 receptor agonists. Overall, only 2.7% of the population were covered by prescriptions for all 3 evidence‐based therapies, and 37.4% were on none of them. Over a 12‐month period, 70.6% of patients saw a cardiologist, while only 18% saw an endocrinologist. Increasing the use of evidence‐based therapies to 100% over 3 years of treatment could be expected to reduce 4546 major atherosclerotic cardiovascular events (myocardial infarction, stroke, or cardiovascular death) in eligible but untreated patients. Conclusions Alarming gaps exist in the contemporary use of evidence‐based therapies in this large population of insured patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. These data provide a call to action for patients, providers, industry, regulators, professional societies, and payers to close these gaps in care.

Use of Lipid-, Blood Pressure–, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease

“…The finding that only 58.6% of patients in this study were prescribed a statin is considerably lower than a recently published estimate of 74.6% from a database of commercially insured patients in the US. 9 Notably, the rate of overall statin use in this study was similar to findings from a comparable Medical Expenditure Panel Survey population from 2013, which reported that only 52.7% of patients with diabetes and ASCVD were receiving a statin. 19 In this context, these new data raise concerns that despite strengthening of guideline recommendations in the years prior to our study window, 20 there has been minimal progress in increasing the use of these widely available, cost-effective, safe, and proven medications in the general population.…”

Understanding the place for GLP‐1RA therapy: Translating guidelines for treatment of type 2 diabetes into everyday clinical practice and patient selection

“…In a recently published study including more than 150 000 patients with T2D and ASCVD from the US, only 2.7% were covered by all three CV protective agents which include statins, angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker, and SGLT‐2i or GLP‐1RA 82 . In addition, 37.4% did not receive any CV beneficial agents.…”

“…Over the last years, the T2D treatment guidelines have frequently been changed and updated, and it can be challenging to keep up with the newest recommendations issued by different organizations 92,93 . Patients with T2D and CVD more frequently encounter a cardiologist and a PCP than a diabetologist 82,94,95 . A global survey among PCPs shows that PCPs are aware of the beneficial CV effect found in some CVOTs, but do not find the clinical implications to be fully clear 83 .…”

“…Even though there has been an increased awareness among cardiologists of glucose‐lowering therapies with CV benefits over the last years, 96 the overall prescription remains low 97‐99 (under 2% of national prescribing in the US in year 2020 96 ). Over 12 months, more than 70% of patients with T2D and ASCVD in the USA encountered a cardiologist, while only 18% encountered an endocrinologist 82 . Thus, it is mandatory that focus is on bridging the gap between the cardiologists and the prescription of CV beneficial glucose‐lowering therapies.…”

A Comprehensive Cardiovascular-Renal-Metabolic Risk Reduction Approach to Patients with Type 2 Diabetes Mellitus

“…Despite their overwhelming cardiovascular-renalmetabolic benefit, SGLT2i and GLP1RA were prescribed in only 10.2% of patients with type 2 diabetes mellitus and cardiovascular disease in a large, US-based commercial insurance cohort. 84 In this same cohort,~25% of individuals were on a high-intensity statin,~53% were on angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) therapy, and only 2.7% were on all 3 groups of medications: high-intensity statin, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, and SGLT2i/GLP1RA.…”