Racial Disparities and Barrier to Statin Utilization in Patients with Diabetes in the U.S. School of Pharmacy Virginia Commonwealth University

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1 Racial Disparities and Barrier to Statin Utilization in Patients with Diabetes in the U.S. School of Pharmacy Virginia Commonwealth University

2 Outline Background Motivation Objectives Study design Results Conclusion Limitations

3 Background: Diabetes affects 24 millions people (8%) of the U.S. population (CDC press release, 2008) Ranked 8 th most costly medical condition in the U.S. (Druss et al, 2002) Prevalence of type2 diabetes, rate of morbidity and mortality associated with diabetes is higher in African-American compared with Caucasian (Marshall, 2005)

4 Background: African American were less likely than whites to be given lipid-lowering medications among veterans with type 2 diabetes (Safford et al, 2003) African-American had poorer cholesterol control but similar or more appropriate intensification of therapy compared to whites (Brown et al, 2005) Racial disparities were lowered in LDL testing and control but remained in statin use (Sequist et al, 2006)

5 Background: Lower proportion of uninsured adult diabetes patients received eye and foot examination (Commonwealth Fund, 2001) Diabetes patients with different types of health insurance coverage received varying quality of diabetes care (Zhang et al, 2008)

6 Motivation Statin (HMG Co-A reductase inhibitor) is recommended as first line therapy for all diabetes patients who are at sufficiently high risk of vascular event (NCEP III & Standard of Medical Care in Diabetes, 2009) No recent studies assess racial disparities in statin utilization in diabetes patients Racial disparities can be confounded by insurance status but has rarely been controlled for

7 Objectives To use Medical Expenditure Surveys Data (MEPS) to assess racial disparities in statin utilization controlling for insurance status in diabetes patients To use MEPS to assess Out-of-Pocket payments for statin by insurance status in diabetes patients

8 Study Design MEPS 2004 data Nationally representative sample of 1,845 noninstitutionalized diabetes patients between years old Cross-sectional study Multivariate logistic regression analysis and Generalized linear model analysis

9 Study Design: Race (discrete nominal) Gender (discrete nominal) Marital status (discrete nominal) Persons Education (discrete - ordinal) Family income (discrete ordinal) Process of care: Statin usage (discrete) Family size (discrete - ordinal) Access Payors Insurance status (discrete nominal) Prescription drug coverage (discrete nominal) Patients Co-morbid condition (discrete- nominal) Age (continuous- interval scale) Age square (continuous interval scale) (Chin et al, 2007)

10 Study Design: 4 races (Caucasian, African American, Asian and other races) and 1 ethnic group (Hispanic) 6 mutually exclusive insurance status categorized by hierarchy order (Zhang et al, 2008) Insurance status Medicare Medicaid Dual Eligible Private Definition Medicare with NO Medicaid Medicaid with NO Medicare Medicare WITH Medicaid Private insurance Uninsured No insurance during all of 2004 Other Mixed medical payment methods

11 Study Design: Bivariate chi-square tests to assess the association between race/ethnicity and statin use, and insurance status and statin use Multivariate logistic regression analysis controlling for socioeconomic variables, comorbid conditions and complex sample design

12 Results: By race/ethnicity Age* (SD) All Caucasian African American 59.7 (14.28) 60.4 (14.26) 58.0* (14.22) Asian 61.2 (11.85) Other races 52.2* (14.28) Hispanic 57.0* (14.44) P-value (races) Female (%) < Married (%) < High school graduate (%) Below middle income (%) Family size >= 2 (%) < < * p < 0.05 with respect to mean age of Caucasian patients p-value < 0.05 compared across ethnic groups

13 Results: Age *(SD) By insurance status All Medicare Medicaid 59.7 (14.28) 72.3 (8.24) 48.7* (10.12) Dual Eligible 66.7* (12.03) Private Other Uninsured P-value 51.3* (9.30) 50.1* (9.86) 48.0* (12.17) Female (%) < Married (%) < High school graduate (%) Below middle income (%) Family size >= 2 (%) < < < * p < with respect to mean age of patients in Medicare Group

14 Results: % Statin use by race (p<0.0001)/ethnicity (p=0.0006) CaucasianAfrican American Asian Other races Hispanic

15 Results: % Statin use by insurance status (p<0.0001) Medicare Medicaid Dual Private Other Uninsured

16 Results: Race/ethnicity Predictor Adjusted OR 95% CI African American 0.47* Insurance status Asian Hispanic Other races Medicare 1.79* Medicaid 1.96* Dual 1.96* Private Other 2.91* * p-value < 0.05 : Results from multivariate logistic regression analysis adjusting for socioeconomic variables, co-morbid conditions and complex sample design

17 Results: Costs of statin in 2004 by insurance status Total cost of statin and amount paid Out-of-Pocket per prescription ($) Total cost Out-of-Pocket Medicare* Medicaid Dual Private* Other* Uninsured* * p-value < amount paid Out-of-Pocket compared to Medicaid group: Results from the analysis using generalized linear model with log link function and gamma distribution

18 Conclusion Compared to Caucasian, African American were less likely to use statin Use of statin was associated with insurance status Out-of-Pocket payments varied by insurance status

19 Limitations Clinical outcomes such as LDL level unknown Used co-morbid condition to control (CVD) Unable to exclude women with gestational diabetes diagnosis

20 Acknowledgement Pharmaceutical Economics and Policy Program (PEP) Graduate Fellowship, School of Pharmacy, Virginia Commonwealth University

21 Thank You School of Pharmacy Virginia Commonwealth University

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