Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville.
Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville.
J Manag Care Spec Pharm. 2024 Nov;30(11):1298-1307. doi: 10.18553/jmcp.2024.30.11.1298.
Two classes of newer glucose-lowering drugs (GLDs), sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, improve cardiovascular and renal outcomes among patients with type 2 diabetes (T2D). However, racial and ethnic minority groups carry higher cardiovascular risks but have lower access to newer GLDs. Contextual-level social determinants of health (SDOH) may be the underlying factor associated with newer GLD adoption.
To identify the association between contextual-level SDOH and real-world adoption of newer GLDs among Medicare beneficiaries and to examine the nonstationarity in the associations.
Data were from 15% random samples of January 2017 to December 2018 nationwide Medicare beneficiaries. We identified patients with T2D who did not use newer GLDs in the year before the index date-January 1, 2018-and followed the cohort for 1 year to record their status of initiating a newer GLD. We used a geographically weighted multivariable Poisson regression model to determine to what extent the SDOH-newer GLD initiation association (β coefficient) varied geographically.
We identified 795,469 eligible Medicare beneficiaries with T2D during the study period from our dataset. Of the study cohort, mean age was 73.1 (SD = 10.5) years, 424,312 (53.3%) were female, 562,994 (70.8%) were non-Hispanic White, 96,891 (12.2%) were non-Hispanic Black, 84,744 (10.6%) were Hispanic, and 29,645 (3.7%) were Asian/Pacific Islander. Newer GLD initiation was negatively associated with the percentage of the population reporting non-Hispanic Black race, Hispanic ethnicity, and unemployment, as revealed by nonspatial regression analyses. The county-level median household income was also associated with higher newer GLD initiation. The spatial analysis presented distinct distributions of local parameter estimates for each contextual-level SDOH.
We identified key contextual-level SDOH associated with real-world adoption of newer GLDs and explored their geographic variation through spatially explicit, data-driven analytical approaches. Identifying areas of strong association between SDOH and newer GLD initiation is crucial for policymakers to allocate resources and develop interventions that address structural inequities.
两类新型降糖药物（GLD），钠-葡萄糖共转运蛋白 2 抑制剂和胰高血糖素样肽-1 受体激动剂，改善了 2 型糖尿病（T2D）患者的心血管和肾脏结局。然而，少数族裔群体的心血管风险更高，但获得新型 GLD 的机会却更少。健康的社会决定因素（SDOH）可能是与新型 GLD 采用相关的潜在因素。
确定医疗保险受益人群中社会决定因素与新型 GLD 实际采用之间的关系，并检验关联的非平稳性。
数据来自全国医疗保险 2017 年 1 月至 2018 年 12 月的 15%随机样本。我们确定了索引日期（2018 年 1 月 1 日）前一年未使用新型 GLD 的 T2D 患者，并对该队列进行了为期 1 年的随访，以记录他们开始使用新型 GLD 的情况。我们使用地理加权多变量泊松回归模型来确定社会决定因素-新型 GLD 起始关联（β系数）在多大程度上存在地域差异。
从我们的数据库中，我们确定了研究期间符合条件的 795469 名有 T2D 的医疗保险受益患者。在研究队列中，平均年龄为 73.1（SD=10.5）岁，424312（53.3%）为女性，562994（70.8%）为非西班牙裔白人，96891（12.2%）为非西班牙裔黑人，84744（10.6%）为西班牙裔，29645（3.7%）为亚洲/太平洋岛民。非空间回归分析显示，新型 GLD 起始与报告非西班牙裔黑人比例、西班牙裔比例和失业率的人群百分比呈负相关。县一级的家庭收入中位数也与更高的新型 GLD 起始相关。空间分析呈现了每个社会决定因素的局部参数估计的独特分布。
我们确定了与新型 GLD 实际采用相关的关键社会决定因素，并通过空间明确、数据驱动的分析方法探索了它们的地理差异。确定社会决定因素与新型 GLD 起始之间的强关联区域对于政策制定者分配资源和制定解决结构性不平等问题的干预措施至关重要。
