Socioeconomic factors and SGLT2 inhibitor prescription in heart failure a retrospective analysis using real-world data

Abstract Background Socioeconomic status, both individual and area-based, is linked to incident coronary artery disease, heart failure, and adverse cardiovascular outcomes. Whether this association reflects differences in risk factor profiles, access to and quality of treatment, or a combination of these factors remains unclear. Purpose To analyse associations of socioeconomic factors and SGLT2 inhibitor (SGLT2i) prescription as an indicator of high quality therapy in heat failure. SGLT2i are recommended by the 2023 ESC guidelines for patients with heart failure irrespective of left ventricular ejection fraction. Methods This retrospective analysis used German health insurance claims data of 2022 and 2023 for over 2.8 million individuals. Heart failure was defined as ICD-10-GM codes I50.1 and I50.9, and incident heart failure as the absence of the respective ICD-10-GM codes in the preceding year. Area-based socioeconomic data were obtained from the INKAR database at the municipality level. Patients with type 1 diabetes mellitus or end-stage renal disease were excluded as they represent contraindications for SGLT2i use. Associations were assessed using multivariable logistic regression. Results In 2023, a total of 90,841 subjects were diagnosed with heart failure, with 31% of them being incident cases. The median age was 73 years. 23,448 subjects with heart failure received at least one SGLT2i prescription (Table). Individual-level predictors of SGLT2i prescription included incident heart failure, diabetes mellitus type 2, older age, enrolment in a disease management program, and German nationality. Female sex and receiving unemployment benefits were negative predictors. At the municipal level, residing in a higher-income tax municipality, in an area with a hospital providing acute cardiac care, or in a medium-sized town, and a higher density of pharmacies were positive predictors of SGLT2i prescription (Figure). Other social factors such as job loss, moving, the number of hospital beds per capita, and living in a big city were correlated with SGLT2i prescription. Conclusion Individuals with lower socioeconomic status, both at the individual and municipal levels, are significantly less likely to receive SGLT2i treatment for heart failure. Focusing on individuals with socioeconomic disparities appears to be essential for improving heart failure care. Table: Distribution of sex, incidence of heart failure, and prevalence of diabetes in subjects with at least one prescription of SGLT2 inhibitors in 2023. Figure: Forest Plot of significant coefficients (±95% confidence interval) of the logistic regression model regarding the influence of socioeconomic factors on prescription of SGLT2 inhibitors in heart failure.