Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal GDMT Following HFrEF Diagnosis Among Medicare Beneficiaries

doi:10.1016/j.jchf.2023.08.027

Heart failure & cardiomyopathiesCohort study

Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal Guideline-directed Medical Therapy (GDMT) Following Heart Failure with Reduced Ejection Fraction (HFrEF) Diagnosis Among Medicare Beneficiaries

JACC Heart FailPublished 8 Nov 2023

Retrospective cohort study
5% Medicare sample

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Authors' conclusion

Use of optimal GDMT following new-onset HFrEF diagnosis is low, with substantially lower use noted among patients living in rural vs urban locations. Suboptimal GDMT use following new-onset HFrEF was associated with an increased risk of mortality and subsequent HF hospitalization.

Study context

Population: Medicare beneficiaries with new-onset HFrEF, January 2015–December 202027.6% rural
Participants: 41,296 beneficiaries

Exposure: Rural vs urban residence; optimal GDMT vs not
Outcome: Time to optimal triple GDMT achievement (primary exposure: rural vs urban residence)
Follow-up: 12-month follow-up

Main finding

Optimal GDMT use · 12 months

Hazard ratio

0.92

95% CI 0.86–0.98

P = 0.01

By group

Rural8.4%

Urban9.3%

Rural vs Urban

HR 0.92 (95% CI 0.86–0.98); P = 0.01

As reported in the abstract

Observational data: associations, not effects.

Further findings

Outcome	Lower risk with optimal GDMT ←→ Higher risk with optimal GDMT	HR (95% CI)	P value
Optimal GDMT on follow-up vs not: all-cause death and HF hospitalization — Optimal GDMT vs Urban · death		0.89 (0.85–0.94)	P < 0.001
Optimal GDMT on follow-up vs not: all-cause death and HF hospitalization — Optimal GDMT vs Urban · subsequent HF hospitalization		0.93 (0.87–0.98)	P = 0.02
	0.512Hazard ratio (log scale)

GDMT use over 12-month follow-up (overall)

Initiated on any dose of triple GDMT: 22.5%
On optimal GDMT doses: 9.1%

Excess mortality risk in rural vs urban explained by GDMT differences

Share of excess mortality risk accounted for by differences in optimal GDMT use: 16%

Original publication

Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal GDMT Following HFrEF Diagnosis Among Medicare Beneficiaries. JACC Heart Fail. Published 8 November 2023. doi:10.1016/j.jchf.2023.08.027

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Summarised from the published abstract; every number is checked against it