Introduction

The prescription of sodium-glucose cotransporter-2 inhibitors (SGLT2is) for heart failure management has seen a remarkable uptick since 2021, particularly for patients with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF). However, significant disparities in prescribing practices continue to exist among hospitals across the United States, according to a recent study published in JAMA Cardiology utilizing data from the Get With The Guidelines–Heart Failure (GWTG-HF) registry.

Prescribing Trends

The analysis revealed a striking increase in the discharge prescriptions of SGLT2is from just 4.2% in mid-2021 to 23.5% by late 2023 for patients with a left ventricular ejection fraction (LVEF) exceeding 40%. This surge can be attributed to findings from successful clinical trials, notably the EMPEROR-Preserved trial, which demonstrated the benefits of these medications in managing heart failure.

Disparities in Prescription Rates

Despite this progress, the study, encompassing 158,849 heart failure patients across 557 U.S. hospitals, found that only 13.9% of these patients received an SGLT2i upon discharge. The median prescription rate varied widely, at just 10.9% overall, indicating that the chances of receiving these potentially life-saving medications can more than double depending on the hospital setting.

“This variation underlines the critical need to investigate the practices of hospitals that are successfully increasing SGLT2i adoption,” commented the authors of the study.

Patient Characteristics and Insurance

Intriguingly, prescription rates showed that patients with mildly reduced LVEF (41%-49%) were favored for SGLT2i prescriptions compared to those with preserved LVEF (≥50%), with rates of 18.5% versus 13%, respectively. The analysis noted that patients with Medicaid insurance or those suffering from atrial fibrillation were also more frequently prescribed these medications, while patients with kidney failure or anemia had lower rates of prescription.

Demographic Factors

Demographic factors played a notable role as well: younger patients, individuals with type 2 diabetes, and those identifying as Black, Hispanic, or from other non-White ethnic groups were more likely to be prescribed SGLT2is. Particularly, among patients with type 2 diabetes, prescriptions increased significantly from 7.5% to 30.3% within a two-year period.

Gender Disparities

However, a concerning trend emerged in gender disparities; women were less likely than men to receive prescriptions for SGLT2is. The authors speculated that this may be due to clinician apprehension regarding potential risks for urogenital infections and concerns from patients about experiencing adverse reactions.

Hospital Practices

The data showcased that of 518 hospitals with at least 10 eligible discharges, a mere 11 hospitals prescribed SGLT2is to over half of their eligible patients, while almost 45% of hospitals discharged fewer than 10% of applicable patients with these medications.

Recommendations for Improvement

To counteract these concerning trends, the authors suggested that educational initiatives, electronic prescribing alerts, and performance feedback could enhance prescription rates. Furthermore, national programs like the GWTG-HF registry’s quality measures could serve as frameworks to boost SGLT2i adoption across hospitals nationwide.

Conclusion

In light of these findings, while the rapid adoption of SGLT2 inhibitors is commendable, it underscores the critical need to address the underlying disparities in prescribing practices that could significantly affect patient outcomes. However, this study does come with limitations, including a lack of data on post-discharge medication adherence and the involvement of cardiology teams in patient care. Moreover, while prescription trends were assessed, the long-term effects of SGLT2i use on outcomes such as mortality rates or rehospitalization were not evaluated.

As the heart failure landscape evolves with the integration of newer therapies, understanding and addressing these disparities will be key to ensuring equitable access to effective treatment for all patients.