Disparities in Outpatient Management of Type 2 Diabetes

In this podcast, Chandler Howell, PharmD, speaks about the guideline-recommended first and second-line treatment options for type 2 diabetes, the pharmacist involvement in the care of people with diabetes, and gaps that exist in access to medication for people with fewer financial resources. He presented on this topic at ADCES21. 

Additional Resource:

  • Howell C, Albertson S, Hamm J, et al. Disparities in outpatient management of type 2 diabetes. Talk presented at: Association of Diabetes Care & Education Specialists Conference; August 12-15, 2021; Virtual.

Chandler Howell, PharmD, is a clinical pharmacy specialist in ambulatory care at Franciscan Health in Indianapolis, Indiana. 



Jessica Bard: Hello, everyone. Welcome to another installment of "Podcast 360", your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

According to the CDC, more than 34 million people have diabetes in the United States. That's more than 10 percent of the population in the United States.

Dr Chandler Howell is here to speak with us about his team's research disparities in outpatient management of type 2 diabetes presented at, ADCES 2021. Dr Howell is a clinical pharmacist specialist in ambulatory care with Franciscan Health in Indianapolis, Indiana.

Thank you for joining us today, Dr Howell. Can you please give us an overview of your study? What was the purpose? How did it come about?

Dr Chandler Howell: Sure. Part of every residency program is being able to do a research project. I have a very wide aspect of interest. I'm very passionate about type 2 diabetes as well as psychiatric care and helping to connect patients to resources and able to get medication.

This is a project that actually came about, because my project mentor, Dr Jasmine Gonzalo, informed me of the look‑ahead study, and a secondary analysis that have recently been done on that.

It looked directly at the prescribing of GLP‑1 agonists, SGLT2 inhibitors, and DPP‑4 inhibitors, and how they were prescribed by statistical significant less incidents, and patients of a black race, and also patients that had a lower economic status.

Eskenazi Health, where I did my residency training, was the underserved safety health care network system for the Indianapolis area. This is something that's important to us.

Is to make sure that patients of lower economic status and of any race or ethnicity that are coming to us, they're going to receive the same quality of care. We want to look at our specific patient population.

Since this study wasn't fully published online, that was just a little bit of information you can get right now from the ADA, is a little snippet that they gave up on this presentation that was given at the American Diabetes Association Conference last year.

We wanted to look specifically at our patient population and see, was this still the same? Were we going to see the same evidence that what they found in their study, or we're going to see things that were different?

We also wanted to look more deeply to see what maybe some of these causes were and to see whether our pharmacists could have an impact on this.

Bard: Let's dive into your study a little bit. What are the guideline‑recommended first and second‑line treatment options for type 2 diabetes?

Dr Howell: The American Diabetes Association right now, wants every patient with type 2 diabetes, if they can tolerate metformin to be on metformin. That's the first‑line treatment agent for any patients that have diabetes.

The second‑line agents are recommended based of comorbidities. Based off of patients either being obese and having CKD, heart failure, any of these disease states are going to point towards patients being on a GLP‑1 agonist and SGLT2 inhibitor next, which isn't going to, of course, be all patients.

Considering how relevant obesity is in diabetes, it's almost all patients. These are the only agents that also come with cardiovascular benefit, and also benefits based off getting disease as well.

There are a number of reasons that patients should be on these next. The guidelines point toward these being our best agents to use after metformin.

The majority of patients with type 2 diabetes should be on these particular agents, even if they're requiring insulin, is going to help get their insulin requirements down.

These should be the second‑line agents that the American Diabetes Association points to, that we should be using as practitioners next.

Bard: Let's talk about some of the gaps in access. What gaps exist in regard to medication access for people with diabetes and low financial resources?

Dr Howell: There are a lot of gaps that exist. GLP‑1 agonists, SGLT2 inhibitors, these are medications that are fairly new to the market. They've been around for a while, but they're still only right now brand medications.

There are no generics that are available. There are programs that are out there. Unfortunately, these don't always cover the gaps that patients have.

Copay cards exist for most of these agents, but a copay card only covers up to a certain amount a year. For some of these patients, their co‑payments from their insurance are so high, that they're not going to be able to have these agents still for the entire year.

Copay cards alone aren't enough for the majority of patients. Patients Savings Programs also exist for most of these agents. Again, patients have to meet specific standards to achieve these agents. You have to have a low enough income to qualify.

Getting these agents prescribed to patients, even though we know these are the best agents, can be a hard problem for practitioners. Sometimes it takes a really creative solution in order to get patients to have these medications. There are a lot of gaps for them to be able to get these expensive agents on the market.

Bard: What is the pharmacist involvement in care of people with diabetes?

Dr Howell: The pharmacist involvement for people with diabetes has being extremely involved in the care for the patients based off of what we can now do with ambulatory care pharmacy.

Ambulatory care pharmacy has evolved to patients with type 2 diabetes being able to be managed by an ambulatory care pharmacist.

Once that diagnosis is made by a physician, that the patient has type 2 diabetes, been sent to a pharmacist that works in collaboration with those physicians to manage the entire disease state after that diagnosis is made.

Also, the pharmacist can have a big impact on the care by again, going back to what we talked about with type 2 diabetes, that these are expensive agents. Pharmacists are a little bit more unique with our training and schooling.

During residency, we are trained on all the ways to help patients obtain access, which is very different from a lot of practitioners that don't receive that same type of training on how to get access to patients.

It puts us in a unique situation to now be able to prescribe one of these collaborative practice agreements with physicians, while also having that background knowledge of how to obtain access for the patient.

Bard: You mentioned in the beginning of this podcast why this was so important to you. Did any of these findings surprise you?

Dr Howell: Yes. I would say that some of the findings did surprise me. I was not surprised to see...Well, I was very happy to see that we didn't have those disparities in care when looking at our particular organization based off of race, gender.

All the aspects we were looking at including even serious mental illness. We did not see any differences in any of these particular patterns with the prescribing of GLP‑1s or SGLT2s. I was extremely surprised to see how different the prescribing rates of this agents were in general though, between patients that were only being managed by physician against patients that were being managed by both a pharmacist working in collaboration with a physician.

Our rates were for all races were just about under 20 percent, for patients that were being managed by a physician alone, compared to around 60 percent, for all the groups that were being managed in relation to a prescriber, and a pharmacist working collaboratively.

When I say the 60 percent, I'm talking about patients being prescribed either a GLP‑1 or an SGLT2. Many more patients had this on board when a pharmacist was involved.

I thought that it would be higher in the pharmacist group based off of again, going back to our knowledge on how to obtain access and to get patients to be able to afford these agents. I didn't think it would be that drastic of an amount. That was a very surprising thing that I saw during this research project.

Bard: To sum it up, what are the overall take‑home messages from your study?

Dr Howell: The take‑home messages from my study were that right now, at least, in some organizations that appears that this difference that was found when looking overall might not exist.

One of the most important things to keep in mind is that Eskenazi Health. They are a underserved safety health care network system. They have more systems in place to make sure that there are access for patients.

We have a specialist team at Eskenazi that works to make sure that anyone who's having a financial gap, that you can send these patients to them. They will find a way to lift the providers or pharmacists or struggling themselves to help them get access. There's a lot of things in place for patients.

I think that one of the take‑home messages is this could be a very effective way to avoid these disparities in care.

I also think that in general, showing that a pharmacists involvement could also be something that in general could help those disparities in care for any group because our rates should be high for prescribing these agents.

Again, going back to the American Diabetes Association Guidelines, GLP‑1s, SGLT2s, we know the benefits these agents can have for patients. That they don't come with the weight gain and the hypoglycemia, that we see with many of our other agents on the markets.

The more people we can get on these medications, the better. A take‑home message is that having a pharmacist involved in the team seems to have a big impact on getting these agents on board for patients regimens.

Bard: What's next for research in this area?

Dr Howell: What's next for research in this area is finding why that difference again, and why that disparity of difference in care happens within the races for that original study that this was based off of.

We know that from looking at that study that that difference did exist. My study, I was unable to find why that difference existed. Being able to expand this more, as this was just a single‑center study, is going to be really important.

Looking at different healthcare systems around the area of the US is going to be important to see when this huge national study was done, that they did see this difference.

I think that there still is that unanswered question that exists. I think that doing more studies are going to be really important to find out why they found out with the original study.

Bard: Is there anything else that you'd like to add at all, anything that we've missed?

Dr Howell: One thing that I would like to add was in considering this study was the fact that we did have a very unique patient population. This study was done, and it was an underserved patient population.

What our patient population looks like at Eskenazi is going to be very different when looking at any other health system. The results of this study are something to consider that other safety, health care, and network systems could probably utilize this data.

It is hard to use this external validity to other healthcare systems that could have very different patient population. I think that is one thing that's going to be important to consider, what that is and why again, more studies are needed to conduct on the same subject to make sure that these disparities and carriers, don't exist in other health care systems.

Another thing that I would like to add to is, this wasn't the only other difference that was found. The only other difference that was found in terms of a statistical significant difference during this particular study, other than the pharmacist involvement, was seeing that there was a difference also in terms of patients being prescribed these agents while there were insured.

When running a logistical regression test during this particular study with all the data, combined both the physicians and also the pharmacists being involved with the physician care.

What we saw was that the biggest impacting factor is when a pharmacist is involved in the care. The second most impacting factor we found was insurance status.

Making sure that our patients are insured or have some connection, whether that be helping a patient that's uninsured for Medicaid, or helping them to get a commercial plan signed up for.

We found that this was the second most impacting factor on whether or not someone had these agents, which wasn't too big a surprise, of course, considering how expensive these agents are, but again going to show how important it is to make sure our patients are connected to insurance and have those resources available to them.

Bard: Thank you so much for your time today. We appreciate it.

Dr Howell: Thank you.