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. 2022 Nov;15(11):e009395.
doi: 10.1161/CIRCHEARTFAILURE.121.009395. Epub 2022 Nov 15.

Clinical and Socioeconomic Determinants of Angiotensin Receptor-Neprilysin Inhibitor Prescription at Hospital Discharge in Patients With Heart Failure With Reduced Ejection Fraction

Jeffrey S Tran  1 , Macklin G Loveland  1 , Ahmad Alamer  2 , Ileana L Piña  3 , Nancy K Sweitzer  1
Affiliations

Clinical and Socioeconomic Determinants of Angiotensin Receptor-Neprilysin Inhibitor Prescription at Hospital Discharge in Patients With Heart Failure With Reduced Ejection Fraction

Jeffrey S Tran et al. Circ Heart Fail. 2022 Nov.

Abstract

Background: Angiotensin receptor-neprilysin inhibitor (ARNI) prescription in the United States remains suboptimal despite strong evidence for efficacy and value in heart failure with reduced ejection fraction. Factors responsible for under prescription are not completely understood. Economic limitations may play a disproportionate role in reduced access for some patients.

Methods: This is an analysis of the Get With The Guidelines-Heart Failure registry, supplemented with data from the Distressed Community Index. Data were fit to a mixed-effects regression model to investigate clinical and socioeconomic factors associated with ARNI prescription at hospital discharge. Missing data were handled by multilevel multiple imputation.

Results: Of the 136 144 patients included in analysis, 12.6% were prescribed an ARNI at discharge. The dominant determinants of ARNI prescription were ARNI use while inpatient (odds ratio [OR], 72 [95% CI, 58-89]; P<0.001) and taking an ARNI before hospitalization (OR 9 [95% CI, 7-13]; P<0.001). Having an ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB)/ARNI contraindication was associated with lower likelihood of ARNI prescription at discharge (OR, 0.11 [95% CI, 0.10-0.12]; P<0.001). Socioeconomic factors associated with lower likelihood of ARNI prescription included having no insurance (OR, 0.60 [95% CI, 0.50-0.72]; P<0.001) and living in a ZIP Code identified as distressed (OR, 0.81 [95% CI, 0.70-0.93]; P=0.010). The rate of ARNI prescription is increasing with time (OR, 2 [95% CI, 1.8-2.3]; P<0.001 for patients discharged in 2020 as opposed to 2017), but the disparity in prescription rates between distressed and prosperous communities appears to be increasing.

Conclusions: Multiple medical and socioeconomic factors contribute to low rates of ARNI prescription at hospital discharge. Potential targets for improving ARNI prescription rates include initiating ARNIs during hospitalization and aggressively addressing patients' access barriers with the support of inpatient social services and pharmacists.

Keywords: heart failure; neprilysin; odds ratio; practice patterns, physicians; socioeconomic factors.

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Figures

Figure 1.
Figure 1.
Consort Diagram of Analysis Population Consort diagram showing sample extraction from the Get with the Guidelines-Heart Failure (GWTG-HF) registry. AMA: against medical advice; ARNI: angiotensin blocker-neprilysin inhibitor; EF: ejection fraction; HFrEF: heart failure with reduced ejection fraction; LVAD: left ventricular assist device.
Figure 2.
Figure 2.
Illustration of Key Findings Illustrated findings of the analysis exploring socioeconomic, clinical, and institutional factors that influence the prescription of angiotensin receptor-neprilysin inhibitors (ARNI) at discharge after hospitalization for heart failure with reduced ejection fraction (HFrEF). The driving determinants are primarily clinical factors, but socioeconomic factors and practice trends over time also play a role. OR: odds ratio.
See this image and copyright information in PMC

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