Certain socioeconomic disadvantages may impact the likelihood of initiating sodium-glucose cotransporter-2 inhibitors following a heart failure diagnosis.
In a retrospective analysis, investigators used 2022 to 2023 German statutory health insurance claims data linked with municipal socioeconomic information from the Indicators, Maps, and Graphics on Spatial and Urban Monitoring database to identify 90,841 patients who had a diagnosis of heart failure in 2023. Following exclusion of patients with prior sodium-glucose cotransporter-2 (SGLT2) inhibitor use, contraindications, mortality during follow-up, or missing data, the final cohort comprised 68,426 treatment-naive patients with heart failure. The primary outcome was initiation of dapagliflozin or empagliflozin during 2023. The investigators used multilevel logistic regression to evaluate associations between patient- and municipality-level socioeconomic factors and treatment initiation, while adjusting for demographics, comorbidities, concomitant heart failure therapies, and other socioeconomic characteristics.
Just 14.2% of the participants initiated SGLT2 inhibitors in 2023. Those with newly coded heart failure had more than twice the odds of treatment initiation, and those newly enrolled in a coronary artery disease management program were also more likely to initiate therapy. Type 2 diabetes, chronic kidney disease, obesity, chronic obstructive pulmonary disease, asthma, and receipt of other guideline-directed heart failure drugs—including sacubitril/valsartan, mineralocorticoid receptor antagonists, beta-blockers, diuretics, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers—were also associated with treatment initiation.
Several demographic and socioeconomic factors were associated with lower treatment initiation. Female participants were less likely to receive SGLT2 inhibitors compared with male participants. Patients who were pensioners, had family insurance, or had recently moved were also less likely to initiate therapy. At the municipality level, residence in a higher-income tax municipality was associated with greater treatment initiation. The investigators estimated that doubling municipal income tax revenue corresponded to an approximately 21% greater likelihood of initiating therapy. By contrast, urbanicity and the presence of a hospital providing acute cardiac care were not independently associated with treatment initiation following adjustment.
Sensitivity analyses using alternative definitions of heart failure produced similar findings for most variables, including sex, newly coded heart failure, disease management program enrollment, and concomitant therapies. However, the association between older age and treatment initiation was no longer statistically significant when analyses were restricted to patients with inpatient heart failure diagnoses, suggesting that health care utilization or case definition may have influenced the finding.
The investigators noted several limitations. Because the study was based on administrative claims data, it could identify associations but could not determine causality. The database did not include clinical variables that may have influenced prescribing decisions. In addition, the definition of newly coded heart failure relied on administrative coding, and exclusion of patients with missing information may have introduced selection bias.
Overall, the findings suggested that socioeconomic and demographic factors may be associated with the initiation of guideline-recommended SGLT2 inhibitor therapy, highlighting potential opportunities to improve the equitable implementation of evidence-based care.
"This study revealed significant socioeconomic and demographic disparities in the initiation of guideline-recommended SGLT2 [inhibitors in] patients with [heart failure] in Germany, a country with high health care expenditures. Addressing these disparities through targeted interventions and policy measures represents a valuable opportunity for improving the quality of care and reducing inequalities in cardiovascular outcomes," wrote lead study author Lisa-Marie Müller, of University Hospital Leipzig, and colleagues.
The study was supported by the German Research Foundation. Full disclosures of the study authors can be found in the study.
Source: Clinical Research in Cardiology
