Real-World Type 2 Diabetes Second-Line Treatment Allocation Among Patients

Objective This study aimed to evaluate the impact of socioeconomic disparities on the allocation of second-line treatments among patients with type 2 diabetes (T2D). Materials and Methods We conducted an observational study using real-world data from over 9 million patients across five University of California Health centers. The study included patients who initiated a second-line T2D medication after metformin, with hemoglobin A1c (HbA1c) measurements within ±7 days of treatment initiation from 2012 through September 2024. Multinomial regression models assessed the association between socioeconomic status and second-line treatment choices. Additionally, we used the GPT-4 large language model with a zero-shot learning approach to analyze 270 clinical notes from 105 UCSF patients. GPT-4 identified adverse social determinants of health (SDOH) across six domains: transportation, housing, relationships, patients with children, support, and employment. Results Among 15,090 patients (56.7% male, 43.3% female; mean age 59.3 years; mean HbA1c 8.91%), second-line treatments included sulfonylureas (SUs; n = 6,732), DPP4 inhibitors (n = 2,918), GLP-1 receptor agonists (n = 2,736), and SGLT2 inhibitors (n = 2,704). Patients from lower socioeconomic neighborhoods were more likely to receive SUs over other medications: DPP4i (OR = 0.96, [95% CI, 0.95-0.98]), GLP-1RA (OR = 0.94, [95% CI, 0.92-0.96]), SGLT2i (OR = 0.95, [95% CI, 0.93-0.97]). In UCSF clinical notes, we identified adverse SDOH including housing (n=8), transportation (n=1), relationships (n=22), employment (n=12), support (n=1), and patients with children (n=25). Conclusions Socioeconomic factors influence second-line T2D treatment choices. Addressing these disparities is essential to ensuring equitable access to advanced T2D therapies.