Health-System and Sex Differences in Cardioprotective Diabetes Therapy Among Adults With Type 2 Diabetes and Established ASCVD: A Two-Center EHR Study
This two-center retrospective study of over 16,000 adults with type 2 diabetes and established atherosclerotic cardiovascular disease reveals that fewer than one-third received guideline-recommended cardioprotective therapies, with significant disparities driven by health system location, sex (specifically lower SGLT2 inhibitor use in women), and neighborhood socioeconomic disadvantage.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Diabetes is a condition where the body struggles to manage sugar, but for millions of adults, the most dangerous threat it poses is not the sugar itself, but the damage it does to the heart and blood vessels. When sugar levels remain high over time, they can harden and narrow the arteries, leading to blockages that cause heart attacks, strokes, or poor blood flow to the legs. In recent years, doctors have gained access to two powerful new types of medicine designed to lower blood sugar while also protecting the heart. One class of drugs helps the kidneys remove excess sugar through urine, while the other works by mimicking a natural hormone that helps the body process food and lowers the risk of heart events. Medical guidelines now strongly recommend these medicines for anyone with diabetes who already has heart disease, yet real-world practice often lags behind the evidence.
A team of researchers set out to understand why these life-saving medicines are not being used more often, and whether the reasons differ between men and women. They looked at the medical records of nearly 17,000 adults with type 2 diabetes and established heart disease across two large hospital systems in the United States: Weill Cornell Medicine in New York and Houston Methodist in Texas. The study covered a period from 2016 to 2023, a time when these therapies were becoming widely known but not yet universally adopted. The researchers wanted to see if the likelihood of receiving these drugs depended on which hospital a patient visited, the patient's sex, or the economic conditions of the neighborhood where they lived. They also examined whether these patterns held true for different types of heart disease, such as blocked arteries in the heart, the legs, or the brain.
The results revealed a significant gap between medical recommendations and actual patient care. Across both hospital systems, fewer than one in three eligible adults received either of the two recommended heart-protective medicines. The usage rates varied sharply depending on the location. At Weill Cornell, about 35 percent of patients received the kidney-targeting drug, compared to only 22 percent at Houston Methodist. Similarly, the hormone-mimicking drug was prescribed to about 30 percent of patients at the New York site, but only 25 percent at the Texas site. These differences suggest that where a patient receives care plays a major role in whether they get access to the best available treatments, regardless of their specific medical needs.
Perhaps the most striking finding concerned the difference between men and women. The study showed that women were significantly less likely to receive the kidney-targeting medicine than men, even after accounting for age, race, income, and other health factors. On average, women had about 29 percent lower odds of receiving this specific drug compared to men. This gap appeared consistently across different types of heart disease and in both hospital systems. For instance, among women with heart failure or kidney disease, the likelihood of receiving the medication remained lower than for their male counterparts. In contrast, the prescribing of the hormone-mimicking drug did not show a consistent difference between men and women overall, though patterns varied slightly between the two locations.
The researchers also looked at how neighborhood poverty, measured by an index of local deprivation, influenced treatment. They found that the disparity in prescribing for women persisted across almost all levels of neighborhood wealth. Whether a woman lived in an affluent area or a disadvantaged one, she was still less likely to receive the kidney-targeting drug than a man with similar health conditions. This suggests that the gap is not simply a result of financial barriers or lack of access in poorer communities, but rather a deeper issue in how these medicines are selected for female patients. The study did not find a single cause for this pattern, but it noted that factors such as concerns about side effects, which can differ between sexes, or unconscious biases in clinical decision-making could be at play.
The study highlights that despite strong evidence showing these drugs prevent heart attacks and strokes, their use remains suboptimal. The fact that fewer than one in three eligible patients received these therapies indicates a missed opportunity to protect public health. The researchers concluded that to fix this, hospitals and health systems need to develop strategies that ensure every patient, regardless of sex or location, receives the standard of care they need. By identifying that women are consistently underserved with a specific, highly effective class of medication, the study points to a clear target for improvement. The goal is to move from a system where treatment depends on chance or location to one where every person with diabetes and heart disease receives the full protection modern medicine offers.
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