Underuse of Evidence-based Therapies for Patients with Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease: Insights from Clinical Research Networks in the United States

Background: Evidence-based therapies for cardiovascular risk reduction are generally underused in patients with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD). While patterns of preventive care have been documented in selected populations, insight into the contemporary use of these evidence-based therapies in broader US populations is lacking. Methods: Data were obtained from 12 health systems with data marts linked to the National Patient-Centered Clinical Research Network. Patients with T2DM and established ASCVD (coronary artery disease, cerebrovascular disease and peripheral artery disease) with a healthcare encounter in 2018 were identified and their lipid, blood pressure and glucose-lowering therapies evaluated. Descriptive analyses were performed on patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin-receptor blocker (ARB), and sodium glucose co-transporter-2 inhibitors (SGLT-2i) or glucagon-like peptide-1 receptor agonist (GLP-1RA). Results: The overall cohort comprised 324,706 patients with mean age 68.2 years, 44.4% were female, 36.0% non-white and 12.8% Latinx. In the prior year, 8.7% visited an endocrinologist, while 26.4% visited a cardiologist and 74.8% visited a primary care physician. Overall, 58.6% were prescribed a statin (26.8% were on a high-intensity formulation), 45.5% were prescribed an ACEi or ARB, and 3.9% were prescribed a GLP-1RA and 2.8% an SGLT-2i. Overall, 4.6% were prescribed all three therapies and 42.5% were prescribed none. Those prescribed either an SGLT-2i or a GLP-1RA were younger, more likely to be privately insured, have fewer comorbidities, more complex T2DM and have seen an endocrinologist. Conclusions: In this large, US national cohort of patients with T2DM and ASCVD, fewer than 1 in 20 patients were prescribed all 3 of a high intensity statin, either an ACEi or ARB and either an SGLT-2i or a GLP-1RA. Multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and their suboptimal use, as confirmed in this large, representative cohort of patients in the United States.