Racial Disparities in Diabetes Treatment; Reducing X-rays

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TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include autoimmune disease and cardiovascular conditions, reducing unnecessary radiographs, preventing kidney injury in cardiac catheterization, and use of effective diabetes drugs in different ethnicities.

Program notes:

0:43 Preventing acute kidney injury in cardiac catheterization

1:43 Point-of-care clinical decision support

2:43 Audit and feedback

3:30 Autoimmune and cardiovascular diseases

4:30 23.3 events per 1,000 patient years

5:30 Even degenerative heart disorders

6:26 Reducing use of x-rays where they may not be useful

7:30 Looked at 3,800 practitioners

8:30 Physicians get upset about being told

9:20 Use of SGLT2 inhibitors and GLP1 agonists in ethnic groups

10:20 Self-identified race

11:20 There is some disparity

12:51 End

Elizabeth: Are there racial disparities in the use of really effective diabetes meds?

Rick: Preventing acute kidney injury in patients undergoing cardiac procedures.

Elizabeth: What is the relationship between autoimmune diseases and cardiovascular diseases?

Rick: Reducing low-value care with regard to radiology procedures.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I’m going to give you carte blanche this morning. Which one would you like to start with?

Rick: Let’s first talk about preventing acute kidney injury in individuals that had cardiac procedures. How’s that?

Elizabeth: Sounds good to me. That’s in JAMA.

Rick: Great. Specifically, we’re talking about procedures in which people get dye — i.e., a radiographic material that allows us to see images, and that’s usually associated with coronary angiography. We know that if you give too much of this dye to individuals it can cause acute kidney injury, especially in those that are already at risk, and we can estimate that.

For years, we have known it can cause acute injury, but we have not done a really good job of trying to prevent that. These investigators devised a specific program that they rolled out to all invasive cardiologists at three cardiac cath labs in Canada. By the way, let’s shout out to one of our long-time listeners and friend, Tom, who has been faithful as a Canadian to listen to us for 19 years. Tom, this is for you.

Here is what they did. They rolled out first of all an education series for an hour and then they had an on-the-spot, point-of-care, clinical decision support. It looked at the specific individual and using their electronic medical records it calculated how much dye they should receive, how much fluid they should receive afterwards, and then they followed up and told them over the course of the quarter how well they did. Did they use too much dye or enough dye, too much fluid, too little fluid?

What they discovered was, in those 31 physicians who performed over 4,300 procedures, they reduced the acute kidney injury rate from 8.6% to 7.2%. That’s a 28% reduction. Audit and feedback afterwards can modify physician experience.

Elizabeth: This model, audit and feedback, is actually the first time I have heard this phraseology. I’m wondering how acceptable it is to clinicians to have this employed.

Rick: So elements are given to the individual physician and actually physicians like it. You have an individualized patient program and then it says how well are you able to keep to that. At least it keeps it in the forefront, so we can get our procedures done and do it safer. That audit and feedback ends up being incredibly useful.

Elizabeth: I think this sounds like a really interesting model. I’m also wondering about this relatively modest reduction and where would you look to reduce it even further? Or is it just not possible to do that?

Rick: Elizabeth, I do think we’re able to do a better job. For example, most of the acute injury that occurred in this subset was in individuals in whom the amount of dye that was recommended was actually exceeded. As you know, Elizabeth, I ran a cardiac cath lab for 20 years and our incidence of acute kidney injury in these individuals who were at high risk when we kept to all of our guidelines was less than 2%. The people who develop acute injury were those who received more dye or less fluid afterwards to wash the dye out. I’m confident we’ll get those numbers even lower, even in high-risk individuals.

Elizabeth: Let’s turn from here to The Lancet. This is a very comprehensive look at the relationship between autoimmune diseases and cardiovascular risk. In this case, they took a look at 19 autoimmune diseases and 12 cardiovascular diseases in 22 million individuals in the United Kingdom, in folks who were newly diagnosed with any of these 19 autoimmune diseases between January of 2000 and the end of December 2017, and people younger than 80 years of age at diagnosis and free of cardiovascular disease up to 12 months after their diagnosis. Then they matched those folks with up to five individuals using the same demographic.

There were almost a half a million individuals with the autoimmune diseases and over two million of the controls. Other patient characteristics: the mean age at diagnosis of their autoimmune disease was 46.2 years, almost 61% of those were women. The incidence rate of cardiovascular disease was 23.3 events per 1,000 patient years if you had an autoimmune disease versus 15 per 1,000 patient years in those without one. They also calculated if you had one autoimmune condition versus two or three. Sure enough, your incidence of cardiovascular disease also went up in a linear way.

The autoimmune diseases that were most problematic: systemic sclerosis, Addison’s disease, systemic lupus, erythematosus, and type 1 diabetes. They conclude then at the end of this study that people with autoimmune disease need to be scrutinized very carefully and managed for their cardiovascular disease risk.

Rick: The amazing thing is that all 19 of them were associated with an increased risk of cardiovascular disease. By the way, it was a variety of cardiovascular diseases. Besides classic atherosclerosis, it included infection-related heart disease, heart inflammation, thromboembolic disease, and even degenerative heart disorders. That tells us it’s not a specific autoimmune disease, but just inflammation in general.

The risk associated with autoimmune disease is the same as increasing blood pressure, having type 2 diabetes, or markedly elevated cholesterol. We need to treat these individuals as if they have a modifiable cardiac risk factor.

Elizabeth: One of the factors that’s kind of buried in their discussion is that they talk about outcomes in patients with autoimmune disease in the JUPITER trial. They say perhaps these results from the JUPITER trial could support the use of statins in patients with autoimmune disease.

Rick: The JUPITER trial tested the use of statins in individuals that had a high C-reactive protein, even if their LDL [low-density lipoprotein] cholesterol wasn’t elevated and it was shown to reduce cardiovascular disease. The authors suggest that this group of individuals would be ideal for testing the use of statins to see if we can reduce the risk of cardiovascular disease. I would totally agree with that.

Elizabeth: Let’s go back to JAMA.

Rick: This is talking about reducing the use of x-rays in situations where they may not be particularly useful. There are a number of musculoskeletal conditions in which tests are ordered where usually unless there is some obvious reason, the x-ray doesn’t provide any additional helpful information. We are talking about things like spine x-rays, or cervical x-rays, or x-rays of the shoulder, hip, or knee when someone sprained it, or someone has just chronic pain where it’s not going to be particularly useful.

What these investigators did is they did a very novel thing. Instead of just putting out all these blurbs and saying, “Okay, here is the authorized use and don’t do it for this,” and you get all these lists that are very difficult to follow, they just targeted the 20% of referrers who were the highest users of these 11 different imaging techniques. They said, “Hey, we want you to know that you’re among the top 20% of users of x-rays.”

They did it in one of two ways. They either notified them one time or two times. They used a visual chart or not. The visual chart would indicate where they were.

When they looked at a total of 3,800 high-requesting general practitioners from over 2,200 practices that were randomized to either notifying them just with words or using visual graphs, they were able to decrease the overall rate of imaging over a 12-month period by about 10%. That was over 47,000 different tests that weren’t ordered during that time period. They call this audit and feedback intervention, just as we talked before.

Elizabeth: Yeah. I would still point to this notion that I’m wondering about individual practitioners and how onerous they may find it or unacceptable they may find it to feel like they are being scrutinized that carefully. I would point to studies that we have talked about before, relative to prescribing of opioids and just how challenging it has been to get people to say, “Hmm, I am being watched and therefore maybe I ought to change my behavior.”

Rick: Being watched is one thing. Being told what to do is another. We all think that our patients are unique and that our practices are somewhat different from the norm. I think physicians really get most upset once they get a note from someone saying you can’t do this or you shouldn’t do this when they don’t know the patient. In this particular case, you just let the physician know, “Hey, you’re in the top 20% of users,” and the physician decides.

Elizabeth: I would also note that this study done in Australia has a different patient population. Here in the U.S. patients frequently come to their practitioners with fairly high expectations, expecting to have something as a result of their visit. I’m wondering how big a factor that is. Somebody just says, “Well, all right, you have back pain. Go and have a CT.”

Rick: Yep, and that’s the easiest way to get around it, Elizabeth. You don’t have to spend much time with the patient. Conversely, if you spend some time and say, “Hey, listen. We know from studies that the CT is not likely to be helpful, but physical therapy can be extremely helpful. We can reserve a CT for later because it exposes you to radiation.” You’re right, there are always tradeoffs.

Elizabeth: Staying in JAMA, finally, let’s turn to one of the things we have examined very closely in lots of different places. That’s inequity among different ethnicities with regard to lots and lots of health interventions.

In this case, it’s the use of two novel therapies for type 2 diabetes and those are SGLT2 inhibitors and GLP-1 receptor agonists. These are newer agents. They are more expensive than everything else that’s going on out there, and it’s already been shown in other populations that there is a disparity among who gets these agents. They are known to reduce the risk of cardiovascular disease and chronic kidney disease progression in folks with type 2 diabetes. People who have private health insurance in other populations have been getting these prescribed more often than those who don’t.

This study took a look at the U.S. Veterans Health Administration’s Corporate Data Warehouse. Wow, that’s got to be a gigantic database. They examined the use of these agents in adult patients with type 2 diabetes and at least two primary care visits for about 2 years. They also looked at self-identified race and ethnicity.

What they basically found, among over a million patients, is that sure enough, if you were white, you are more likely to be prescribed one of these two agents than if you were American Indian, Alaskan Native, Native Hawaiian, other Pacific Islander groups, and then Black or African American patients. Unfortunately, those patients had the lowest odds of being prescribed one of these agents compared with white patients, even though we know that they have a high incidence of type 2 diabetes and chronic kidney disease. The question is, why is this?

Rick: Elizabeth, that’s a great question. I wish I knew the answer, and I wish this study answered it. Unfortunately, it doesn’t, but it is another piece of evidence that suggests there is some disparity and we need to figure out what that is.

There were a couple of things that were disappointing to me about this study. First of all, the reason why this VA population is particularly interesting is allegedly it takes away some of the financial issues. In other words, every veteran ought to have access to the same medications at a relatively nominal cost. Unfortunately, this particular study, even though the cost-sharing is lower in veterans hospitals than in non-veterans hospitals, it’s not negligible.

The other thing that was really disappointing is that, even in the VA population, the use of these medications was under 11% and these are recommended for most individuals with diabetes, regardless of whether their sugar is extremely high to prevent, as you mentioned, cardiovascular disease and kidney disease. There was a 16- to 18-fold difference across different veteran hospital systems. This is disconcerting, Elizabeth.

Elizabeth: I also found it very interesting that there was such a variation among different centers. I also learned a new term, and I don’t know if you were already familiar with this, pharmacoequity. I suspect that we’re going to be hearing a whole lot more about that as time goes on.

Rick: Right. It’s making sure that everybody who needs pharmacologic therapy — i.e., medications — has access to the medications that are recommended based upon guidelines that we know helps either prevent or treat a disease condition.

Elizabeth: On that note then, that is a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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