Related Experiment Video
Updated: Jun 17, 2025
Lumped-Parameter and Finite Element Modeling of Heart Failure with Preserved Ejection Fraction
Published on: February 13, 2021
County-Level Variation in Triple Guideline-Directed Medical Therapy in Heart Failure With Reduced Ejection Fraction
Rishi J Desai1, Danielle Stonely1, Naira Ikram1
1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Insights
County-level heart failure triple therapy use varies significantly across the US. Lower socioeconomic status and higher proportions of Black patients and low-income subsidy recipients correlate with suboptimal guideline-directed medical therapy initiation.
Area of Science:
- Cardiology
- Health Services Research
- Health Equity
Background:
- Current guidelines advocate for the immediate initiation of multiple guideline-directed medical therapy (GDMT) classes for heart failure with reduced ejection fraction (HFrEF).
- Simultaneous initiation of these therapies is crucial for optimal patient outcomes in HFrEF management.
Purpose of the Study:
- To assess the variation in the utilization of triple GDMT (beta-blockers, renin-angiotensin system inhibitors or angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists) across U.S. counties for patients with HFrEF.
- To identify county-level factors associated with disparities in triple GDMT uptake.
Main Methods:
- A retrospective cohort study utilizing Medicare Fee-for-Service claims data (2013-2019).
- Analysis included 304,857 patients across 2,600 U.S. counties.
- Multilevel logistic regression was employed to account for county-level clustering and assess associations between socioeconomic indicators and triple therapy use.
Main Results:
- A median of 14.3% of patients received triple GDMT, with substantial county-level variation (range: 0%-54.5%).
- Counties with the lowest triple therapy use exhibited worse socioeconomic indicators, including higher unemployment rates.
- Lower-use counties also had a higher proportion of Black patients and patients receiving low-income subsidies compared to higher-use counties.
Conclusions:
- Significant geographic variation exists in the adoption of triple GDMT for HFrEF patients in the United States.
- Suboptimal utilization patterns are linked to socioeconomic disadvantage at the county level, highlighting potential health equity concerns.
Background:
Current guidelines recommend simultaneous initiation of multidrug guideline-directed medical therapy classes for heart failure with reduced ejection fraction.
Objectives:
The purpose of this study was to evaluate county-level variation in use of triple guideline-directed medical therapy, defined as simultaneous prescription fills for beta-blockers, renin-angiotensin system inhibitors or angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists, in heart failure with reduced ejection fraction.
Methods:
We conducted a cohort study using Medicare Fee-for-Service claims data (parts A, B, and D between 2013 and 2019). Features of counties including area-level indicators of poverty, employment, and educational attainment and aggregated patient-level sociodemographic and medical history variables were compared by quintiles of triple therapy use. A multilevel logistic regression model was constructed to estimate the contextual effect of clustering by counties, which was expressed as a median OR.
Results:
304,857 patients from 2,600 counties (83% of all U.S. counties) were included. The median for triple therapy use was 14.3% (IQR: 10.3%-18.8%) across included counties with a wide variation (range: 0%-54.5%). Compared to counties in the highest use quintile, counties in lowest triple therapy use quintile had worse area-level indicators of socioeconomic status (% unemployment 6.8% vs 6.2%). Counties in lowest quintile had higher proportion of Black patients (13.3% vs 5.7% in highest quintile) and patients with low-income subsidy (29.3% vs 25.8% in highest quintile). The median OR was 1.30 (95% CI: 1.28-1.33).
Conclusions:
We observed variation in triple therapy use across counties in the United States with suboptimal local use patterns correlating with indicators of socioeconomic disadvantage.
More Related Videos
Related Concept Videos
01:26Heart Failure Drugs: Inhibitors of Renin-Angiotensin System
01:22Heart Failure Drugs: β-Blockers
01:22Heart Failure Drugs: Diuretics
01:17Pathophysiology of Heart Failure
01:26Heart Failure Drugs: Inotropic Agents
01:26Treatment for Pulmonary Arterial Hypertension: Receptor Tyrosine Kinase Inhibitors and Calcium Channel Blockers
TKIs, such as imatinib (Gleevec), are particularly effective in tackling the growth and mitogenic factors that become upregulated in PAH patients. These factors contribute to the...