Guideline-Directed Medical Therapies Focus on Adherence, Cost in Patients With HFrEF

Guideline-directed medical therapies (GDMT) were the focus of a pair of posters presented at the American Heart Association's Scientific Sessions in Chicago, Illinois, November 5- 7, 2022. The posters expanded on the results of studies that aimed to determine the cost of these treatments and how to improve adherence in patients with heart failure with reduced ejection fraction (HFrEF).

The first poster¹ followed an initiative that aimed to improve adherence to GDMT, specifically sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitor (ARNi), which are highlighted in the 2022 ACC/AHA/HFSA Guideline for the Management of HF. The initiative, entitled IMPLEMENT-HF (I-HF), is a national HF quality improvement initiative that focuses on early adoption of GDMT and aims to improve use of SGLT2i and ARNi in patients with HFrEF.

I-HF has several ways to promote education and adherence to GDMT in 7 regions in the United States. These include targeted training, quality improvement consultation, sharing models of clinical care, and resource development. Sharing of interventions is allowed after participation in a learning collaborative. Webinars, pocket guideline booklets, and guideline reminder cards to reinforce GDMT are educational materials that sites receive and all sites collect GDMT data in Get With The Guidelines-Heart Failure (GWTG-HF). ARNi and SGLT2i at discharge was analyzed at baseline (aggregate of Q1 and Q2 2021) through to Q1 of 2022.

There were 62 sites containing 16,533 patient records included in this study. Researchers found that use of ARNi increased from 46% at baseline to 58% in Q1 of 2022 at hospital discharge and use of SGLT2i increased from 8% at baseline to 26% at Q1 of 2022 at hospital discharge.

The researchers concluded that the I-HF initiative was helpful in increasing the use of SGLT2i and ARNi in patients with HFrEF after their hospital discharge.

Cost transparency is key in getting patients to maintain adherence to GDMT. The second poster² focused on determining the national estimates of out-of-pocket (OOP) expenses for GDMT for HF. Researchers used the data from the Medical Expenditure Panel Survey (MEPS) of 2019 to estimate the average annual OOP cost for each GDMT drug: cardio-selective Beta-Blockers (BB), angiotensin-converting enzyme inhibitors (ACEi)/Angiotensin II receptor blockers (ARB)/ARNi, Mineralocorticoid receptor antagonists (MRA), and SGLT2i.

Average annual OOP costs for recommended GDMT combinations were also estimated and all cost estimates were stratified by insurance status.

There were 28,512 participants included in the study, of which 1954 had a prescription for BB, 3642 with at least one prescription of ACEi/ARB, 42 participants with ARNi, 280 with at least 1 prescription for MRA, and 140 with SGLT2i. The average OOP cost for each GDMT drug was $41 (95% CI, $34-$48) for BB, $29 (95% CI, $26-$32) for ACEi/ARB, $192 (95% CI, $111-$274) for ARNi, $32 (95% CI, $25-$39) for MRA, and $151 (95% CI, $110-$191) for SGLT2i.

The average OOP cost for quadruple therapy was $253 in 2019, $292 for privately insured patients, $159 for patients on public insurance, and $975 for uninsured patients. Quadruple therapy with ARNi added approximately $200 to the OOP cost annually. A combination of MRA, BB, and ACEi/ARB cost $282 less when compared with a combination of BB, ARNi, and SGLT2i for triple therapies.

The researchers concluded that insurance coverage was able to substantially mitigate OOP costs. The researchers believed that including estimates of OOP costs for GDMT could increase the proportion of HF patients who initiated and maintained GDMT treatment.

References

1. Yancy Jr CW, Chrkur S, Kiser RY, et al. A national heart failure initiative is associated with improved use of guideline-directed medical therapies. Presented at: AHA 2022; November 5-7, 2022; Chicago, IL. Abstract 537.
2. Alhassan HA, Akunor H, Aryan A, Rollman BL, Luo J, Hickey GW. Average annual out-of-pocket cost of guideline directed medical therapy for heart failure. Presented at: AHA 2022; November 5-7, 2022; Chicago, IL. Abstract 540.