From the 2023 HVPA National Conference
Emily Hansinger MD (Thomas Jefferson University Hospital), Harrison Bell MD, Zoe Begun MD, Claire Zurlo MD, Maria Winte MD, Fernando Cordero-Baez MD, Yair Lev MD
Glucagon-like peptide-1 receptor agonist (GLP-1) medications are well understood in the realm of diabetes management as a well-tolerated medicine with excellent A1c-lowering effects in addition to weight loss. More recently, data has come out showing that there is a significant reduction in major adverse cardiac events (MACE) in patients with known cardiovascular disease (CVD) and type 2 diabetes (T2DM). Despite this evidence, GLP-1s are far underutilized in patients with cardiovascular disease and type 2 diabetes. Cardiologists account for a very small minority of GLP-1 prescriptions. Thomas Jefferson University Hospital (TJUH) in Philadelphia and Jefferson Heart Institute (JHI) could be better serving our patients with increased indicated prescription and access.
Our project aim is to increase GLP-1 use in patients seen at JHI with CVD and T2DM to ~30% by end of 2023. Our interventions are aimed at increasing education of cardiologists about GLP-1s and their indications and increasing the number of prescriptions for appropriately indicated patients.
First, we collected data regarding outpatient visits with cardiology and quantity of GLP-1 prescriptions among patients meeting indications. Then we evaluated reasons for under prescribing. This included surveying cardiologists if they have and are comfortable prescribing GLP-1s, and if not, the reasons why. After collection of baseline prescribing data and reasons for lack of prescribing, we plan to intervene in multiple ways to increase prescribing amounts. This may include: GLP-1 educational information distribution, office staff education regarding prior authorizations, program with pharmacy regarding training and dosing, and multidisciplinary outpatient team consisting of pharmacists, providers, and nursing staff to continue conversations about increasing usage of GLP-1s. We can also use electronic medical record notifications. All of these would be to improve quality of care provided by outpatient cardiology via appropriate medication prescribing.
We found that only 14% of appropriately indicated patients with T2DM and CVD were being prescribed GLP-1’s in the cardiology outpatient setting. This was out of a total of 4,995 total patients meeting indication in 2021. In 2022, the results were similar, again with 14% of patients indicated being prescribed. We are now in the process analyzing survey data from cardiology clinicians to understand the reasons for under-prescribing.
GLP-1’s are under-prescribed in outpatient cardiology and quality improvement measures are needed to improve patient care. Challenges we foresee include: medication access for underserved and uninsured populations, information overload on busy clinicians, inter-professional collaboration in the outpatient setting, evolving clinicians practice habits and preferences, narrowing/defining patient populations, collaborating with community partners, engaging stakeholders, cost and insurance coverage, and patient adherence to medication.
We decided to pursue this project due to the multiple healthcare disparities associated with it, not limited to but including how CVD and T2DM adversely affects underserved populations, how GLP-1s are helpful treatments for both, and how there are also benefits in treating obesity. The greatest challenge may be access to GLP-1s being limited due to cost and insurance barriers. These medical co-morbidities have all been linked to poverty and lifestyle challenges. Our overall goal in regard to healthcare disparities is to create a joint program with social work, pharmacy, and community health workers specifically for patients identified as underserved and who would benefit from GLP-1.