Variations in Use of Diabetes Drugs With Cardiovascular Benefits Among Medicaid Patients

IMPORTANCE: Cardiovascular death remains the leading cause of mortality in patients with type 2 diabetes (T2D). A better understanding of the current use and adoption of glucose-lowering drugs with cardiovascular benefit can inform state policies to ensure their appropriate use in patients with T2D. OBJECTIVE: To characterize the use of glucose-lowering agents with known cardiovascular benefit over time and across states. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional pharmacoepidemiological study of Medicaid prescription rates of glucose-lowering agents with known cardiovascular benefit vs those with less well-established cardiovascular benefit was conducted between 2014 and 2019. In 50 states and the District of Columbia, the study focused on nonmetformin, noninsulin glucose-lowering drugs divided into 3 cohorts: (1) sodium-glucose cotransporter 2 (SGLT2) inhibitors, (2) glucagon-like peptide 1 (GLP1) receptor agonists, and (3) all other classes of glucose-lowering drugs. Data were analyzed from January 2014 to December 2019. MAIN OUTCOMES AND MEASURES: Number of days supplied of each cohort, use ratios between the aggregated days supplied of glucose-lowering agents with known cardiovascular benefit vs those with less well-established cardiovascular benefit, and the mean change in use ratios per quarter. RESULTS: Across the 50 states and the District of Columbia, the use ratio of glucose-lowering agents with known cardiovascular benefit ranged from 1.58 to 0.14 (mean [SD], 0.48 [0.27]) in 2019. A lower use ratio was seen in states with a higher prevalence of diabetes (β = −0.049; 95% CI, −0.086 to −0.012; P = .01), a larger total population (β = −0.013; 95% CI, −0.023 to −0.003; P = .01), a greater number of Medicaid enrollees (β = −0.054; 95% CI, −0.096 to −0.014; P = .01), a greater proportion of people enrolled in Medicaid (β = −0.018; 95% CI, −0.030 to −0.007; P = .002), and a greater proportion of Medicaid patients enrolled in managed care organizations (β = −0.0032; 95% CI, −0.0051 to −0.0013; P = .002). Higher Medicaid expenditures per enrollee (β = 0.047; 95% CI, 0.007 to 0.089; P = .03) were associated with a higher use ratio of these agents. The relative use of glucose-lowering agents with known cardiovascular benefit by Medicaid enrollees increased 7.4% per year from 2014 to 2019, with wide variations across state Medicaid programs. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, glucose-lowering agents with cardiovascular benefit increased in use during the study period, but also demonstrated considerable variation among states in their relative use. Medicaid programs should try to clarify which factors may be contributing to relative underuse of these potentially life-saving drugs.