@article {661405,
	title = {Assessment of Second-Generation Diabetes Medication Initiation Among Medicare Enrollees From 2007 to 2015},
	journal = {JAMA Netw Open},
	volume = {3},
	number = {5},
	year = {2020},
	month = {2020 May 01},
	pages = {e205411},
	abstract = {Importance: Little is known about how new and expensive drugs diffuse into practice affects health care costs.

Objective: To describe the variation in second-generation diabetes drug use among Medicare enrollees between 2007 and 2015.

Design, Setting, and Participants: This population-based, cross-sectional study included data from 100\% of Medicare Parts A, B, and D enrollees who first received diabetes drug therapy from January 1, 2007, to December 31, 2015. Patients with type 1 diabetes were excluded. Data were analyzed beginning in the spring of 2018, and revisions were completed in 2019.

Exposures: For each patient, the initial diabetes drug choice was determined; drugs were classified as first generation (ie, approved before 2000) or second generation (ie, approved after 2000, including dipeptidyl peptidase 4 [DPP-4] inhibitors, glucagon-like peptide-1 [GLP-1] receptor agonists, and sodium-glucose cotransporter-2 [SGLT-2] inhibitors).

Main Outcomes and Measures: The primary outcome was the between-practice variation in use of second-generation diabetes drugs between 2007 and 2015. Practices with use rates of second-generation diabetes drugs more than 1 SD above the mean were considered high prescribing, while those with use rates more than 1 SD below the mean were considered low prescribing.

Results: Among 1 182 233 patients who initiated diabetes drug therapy at 42 977 practices between 2007 and 2015, 1 104 718 (93.4\%) were prescribed a first-generation drug (mean [SD] age, 75.4 [6.7] years; 627 134 [56.8\%] women) and 77 515 (6.6\%) were prescribed a second-generation drug (mean [SD] age, 76.5 [7.2] years; 44 697 [57.7\%] women). By December 2015, 22 457 practices (52.2\%) had used DPP-4 inhibitors once, compared with 3593 practices (8.4\%) that had used a GLP-1 receptor agonist once. Furthermore, 17 452 practices (40.6\%) were using DPP-4 inhibitors in 10\% of eligible patients, while 1286 practices (3.0\%) were using GLP-1 receptor agonists in 10\% of eligible patients, and SGLT-2 inhibitors, available after March 2013, were used at least once by 1716 practices (4.0\%) and used in 10\% of eligible patients by 872 practices (2.0\%) by December 2015. According to Poisson random-effect regression models, beneficiaries in high-prescribing practices were more than 3-fold more likely to receive DPP-4 inhibitors (relative risk, 3.55 [95\% CI, 3.42-3.68]), 24-fold more likely to receive GLP-1 receptor agonists (relative risk, 24.06 [95\% CI, 14.14-40.94]) and 60-fold more likely to receive SGLT-2 inhibitors (relative risk, 60.41 [95\% CI, 15.99-228.22]) compared with beneficiaries in low-prescribing practices.

Conclusions and Relevance: These findings suggest that there was substantial between-practice variation in the use of second-generation diabetes drugs between 2007 and 2015, with a concentration of use among a few prescribers and practices responsible for much of the early diffusion.},
	issn = {2574-3805},
	doi = {10.1001/jamanetworkopen.2020.5411},
	author = {Gilstrap, Lauren G and Blair, Rachel A and Huskamp, Haiden A. and Zelevinsky, Katya and Normand, Sharon-Lise}
}
