Uptake of Guideline-Directed Medical Therapy in Heart Failure With Reduced Ejection Fraction (HFrEF) and Disparities in the United States: A Medicare Database Study

OBJECTIVES: This study aimed to quantify disparities in the receipt of Guideline-Directed Medical Therapy (GDMT) for Heart Failure with Reduced Ejection Fraction (HFrEF) among older U.S. adults based on race, ethnicity, and social determinants of health (SDH) using a large insurance claims database.

METHODS: This was a serial cross-sectional study using a 50% random sample of Medicare fee for service data from 2015 to 2019. Patients over 65 years with an HFrEF diagnosis were identified and analyzed through a validated approach. GDMT was defined as having a dispensing for one of the three following classes: (i) Angiotensin Converting Enzyme inhibitors (ACEi), Angiotensin II receptor blockers (ARBs), or Angiotensin Receptor/Neprilysin inhibitors (ARNIs) (ii) beta-blockers, and (iii) Mineralocorticoid Receptor Antagonists (MRAs). We classified patients by race (White, Black, Hispanic) and assessed county-level SDH using the Social Vulnerability Index. For each of the three drug groups, we modeled the odds of having used GDMT, adjusting for race and ethnicity, age, sex, SVI, and pertinent clinical characteristics.

RESULTS: Among 342,997 Medicare beneficiaries with HFrEF (67.0% male, average age 77.0 years), the overall GDMT rates were 77.9% for an ACE, ARB, or ARNI, 89.4% for beta blockers, and 33.99% for MRAs. Following adjustment for confounders, Black patients and those residing in high social vulnerability areas exhibited a 7% lower likelihood of receiving beta blockers compared to their White counterparts and those from counties with low social vulnerability, as evidenced by an adjusted Odds Ratio (OR) of 0.93 (95% CI: 0.90-0.97) and OR 0.93 (95% CI: 0.90, 0.95), respectively. No similar disparities were observed in the prescription of the other two GDMTs.

CONCLUSIONS: Overall, this study illustrates the significant disparities for beta-blocker therapy for older HFrEF patients, particularly among Black individuals and those in vulnerable areas, highlighting a need for targeted interventions to address these inequities