Health-System and Sex Differences in Cardioprotective Diabetes Therapy Among Adults With Type 2 Diabetes and Established ASCVD: A Two-Center EHR Study

Background Despite compelling evidence that sodium–glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) reduce cardiovascular risk, their implementation among patients most likely to benefit remains suboptimal. We evaluated prescribing patterns, institutional variation, sex disparities, and neighborhood-level socioeconomic disadvantage among adults with type 2 diabetes mellitus (T2DM) and established atherosclerotic cardiovascular disease (ASCVD). Methods We conducted a retrospective cohort study of 16,765 adults with T2DM and ASCVD receiving care at Weill Cornell Medicine (n = 8,669) or Houston Methodist (n = 8,096) between 2016 and 2023. ASCVD was characterized by subtype, including coronary artery disease (CAD), peripheral artery disease (PAD), and stroke/cerebrovascular disease. Prescription prevalence of SGLT2i and GLP-1RA therapy was compared across institutions, ASCVD subtypes, sex, and neighborhood socioeconomic disadvantage measured using the Area Deprivation Index (ADI). Pooled prevalence estimates and sex-specific odds ratios (ORs) were calculated using meta-analytic methods. Results Only 28.3% (95% CI 17.3–42.6) of eligible adults received an SGLT2i, with substantially higher use at Weill Cornell than at Houston Methodist (35.2% vs. 22.2%; P < 0.001). GLP-1RA therapy was prescribed to 27.8% (95% CI 23.1–33.0), also with significant institutional variation (30.4% vs. 25.3%; P < 0.001). Across both health systems, women had 29% lower odds of receiving an SGLT2i than men (OR 0.71, 95% CI 0.66–0.77; P < 0.001), whereas overall GLP-1RA prescribing did not differ by sex. Analyses across CAD, PAD, and stroke and by ADI further evaluated whether treatment gaps varied according to ASCVD phenotype and neighborhood disadvantage. Conclusions Fewer than one in three adults with T2DM and established ASCVD received either class of guideline-recommended cardioprotective therapy. By examining distinct ASCVD subtypes and neighborhood-level deprivation across two health systems, this study demonstrates that treatment gaps extend beyond overall medication use and must be understood within patients’ clinical and socioeconomic contexts. Marked institutional variation and persistent sex disparities in SGLT2i prescribing identify an urgent need for health system–level strategies to standardize care, improve equitable access, and translate cardiovascular outcome evidence into routine practice.