Disease-modifying therapy and hospitalization risk in heart failure patients

To examine comorbidity and therapy use rates in a Medicaid population with heart failure (HF), evaluate hospitalization risk as a function of comorbidity and therapy use, and assess the impact of modification on costs to the Medicaid program.

Historical prospective cohort study. Claims were from adult enrollees in Maryland Medicaid (managed care organization or fee-for-service) diagnosed with HF between 2005 and 2009.

The end point was first hospitalization after index HF. Average hazard ratios (HRs) were estimated by multivariate weighted Cox regression. Budget impact of modifications was assessed using annual number-needed-to-treat calculations and external estimate of average cost of HF hospitalization.

Most patients were >45 years (71%), women (56%), and black (60%). Medication use: beta-blockers (26%), angiotensin-converting enzyme inhibitors and/or angiotensin II receptor antagonists (ACEi/ARBs) (29%), aldosterone antagonists (5%), and others including nitrates-hydralazine (37%). Nearly all (98%) were diagnosed with 1 or more comorbidities. Relative risk of hospitalization was higher with most, but not all, comorbidities investigated. ACEi/ARBs (HR, 0.77; CI, 0.73-0.81), beta-blockers (HR, 0.83; CI, 0.79-0.87), and other cardiovascular drugs (HR, 0.76; CI, 0.72-0.80) had beneficial effects. A 20% increase in the use prevalence of ACEi/ARBs and beta-blockers translated to annual Medicaid savings of at least $85 and $57 per HF patient, respectively.

Findings call attention to comorbidities and optimization of disease-modifying therapy in Medicaid patients with HF. Certain disease-modifying medications mitigated risk, but were used infrequently. Substantive outcome improvement and savings to Medicaid may be achieved with small changes in prescribing rates or comorbidity prevalence.