Date of Award

January 2026

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Shaili Gupta

Abstract

Background: SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1RA) significantly reduce cardiovascular and metabolic risk in type 2 diabetes, cardiovascular disease, and obesity. Yet real-world utilization remains inconsistent, and emerging evidence suggests that social determinants of health (SDOH) may contribute to unequal access and prescribing.Research Aims: The extent and drivers of these disparities have not been systematically characterized, so we conducted a systematic review and meta-analysis to assess whether SDOH—socioeconomic status (SES), insurance status, education, geography, and neighborhood deprivation index (NDI)—and demographic factors—race and sex—are associated with differential utilization of SGLT2i or GLP-1RA. Question: To what extent are SES, insurance status, education, geography, NDI, race and sex associated with differences in utilization of SGLT2i and GLP-1RA? Methods: Six databases (Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar) were searched through February 2025. Retrospective and cross-sectional studies reporting association between at least one SDOH and utilization of SGLT2i and/or GLP-1RA were included. The primary outcome was the adjusted odds of prescription of SGLT2i, GLP-1RA or both drugs by SDOH categories. The secondary outcome was the adjusted odds of prescription fill of SGLT2i, GLP-1RA or both drugs by SDOH categories. Meta-analyses were conducted separately for SGLT2i and GLP-1RA using random-effects models. Risk of bias was assessed using ROBINS-I. Results: Twenty-six studies (>14.6 million patients) were included. Low-SES patients had reduced odds of prescription (aOR 0.73; 95% CI 0.61–0.76) and prescription fill (aOR 0.68; 95% CI 0.51-0.91) for both drugs. Medicaid (aOR 0.70; 95% CI 0.55–0.89), Medicare (aOR 0.73, 95% CI 0.55-0.96), Medicare Advantage (aOR 0.49, 95% CI 0.36-0.68), and non-US publicly insured (aOR 0.41, 95% CI 0.32-0.52) patients all had lower odds of GLP1-RA prescription than privately insured patients. These associations persisted for the secondary outcome. Medicare (aOR 0.68; 0.60–0.78) and Medicare Advantage (aOR 0.41; 95% CI 0.30–0.57) patients had lower odds of SGLT2i prescription than privately insured patients. These associations also existed for the secondary outcome, including for Medicaid patients (aOR 0.88, 95% CI 0.85-0.92). Lower educational attainment (aOR 0.70; 95% CI 0.53–0.93) was associated with reduced prescribing, but did not impact prescription fill (aOR 0.68, 95% CI 0.43–1.09, I² = 65.59%). Rurality was associated with reduced prescribing (aOR 0.91; 95% CI 0.87–0.95) for both drugs, and reduced prescription fill for GLP-1RA alone (aOR 0.70; 95% CI 0.60-0.81). Patients in high-deprivation neighborhoods (aOR 0.80; 95% CI 0.69–0.93) had lower odds of GLP-1RA prescription. Women had lower odds of SGLT2i prescription (aOR 0.89; 95% CI 0.82–0.95), but greater odds of GL P1-RA (aOR 1.33, 1.23-1.43). However, in analyses of prescription fill, women had reduced likelihood of filling both drugs (aOR 0.95, 95% CI 0.94-0.96). Black patients (aOR 0.80; 95% CI 0.79–0.82) had reduced prescribing of both drugs and reduced filling of SGLT2i (aOR 0.84; 95% CI 0.72-0.98), with no significant difference in filling of GLP1-RA (aOR 0.73; 95% CI 0.55-1.03). Hispanic patients (aOR 0.81; 95% CI 0.69–0.96) had reduced odds of being prescribed GLP-1RA and reduced filling both drugs (aOR 0.88, 95% CI 0.86-0.90). Finally, Asian patients (aOR 0.49; 95% CI 0.41–0.58) had reduced odds of receiving GLP-1RA. Statement of Scientific Impact and Relevance for Communities of Interest: Disparities in SGLT2i and GLP-1RA utilization span SES, insurance coverage, education, geography, NDI, race, and sex. Because these therapies meaningfully reduce cardiovascular and metabolic morbidity, unequal access may widen existing health gaps and blunt the population-level benefits these medications can deliver. Understanding where disparities are most pronounced and which social factors are consistently associated with underuse is essential for designing targeted interventions, such as insurance benefit redesign, clinician support tools, community outreach strategies, and policy changes, that can improve equitable access. Addressing these inequities is particularly relevant for health systems, payers, and communities disproportionately affected by cardiometabolic diseases.

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