Uptake of SGLT2i therapy among patients hospitalized with heart failure: Insights from the veterans affairs healthcare system

Abstract

Abstract Introduction Sodium-glucose cotransporter-2 inhibitors (SGLT2i) improve outcomes among heart failure (HF) patients. However, the uptake of SGLT2i over time remains unknown. Purpose This study describes SGLT2i use in Veteran Affairs (VA) patients hospitalized with HF. Methods We identified a patient cohort of VA patients who were hospitalized with HF (primary HF diagnosis or secondary HF diagnosis with intravenous loop diuretics) from January 2019 to December 2022. Patients without VA medication prescriptions, prior allergy to SGLT2i, advanced chronic kidney disease (CKD), end-stage kidney disease (ESKD), and advanced heart failure therapies were excluded. We identified predictors of SGLT2i use in 2022 and compared the SGLT2i prescription rate to the ARNI prescription rate. The hospital-level variation in SGLT2i prescription was assessed via the median odds ratio. Results From 2019-2022, 70,344 VA patients were hospitalized with HF and eligible for SGLT2i therapy (Table 1). The average age was 72.6 years (SD 10.2); 45.5% had EF ≤40%, 12.3% EF 41%-49%, and 42.3% ≥50%. Among this cohort, 11.6% were prescribed SGLT2is at discharge. SGLT2i prescription rates increased over time (Figure 1) and were higher among patients with HFrEF and those with a primary hospital diagnosis of HF. Among 16,426 patients hospitalized in 2022, SGLT2i prescription was more likely among patients with diabetes mellitus (OR 2.27; 95% CI: 2.09-2.46) and ischemic heart disease (OR 1.13; 95% CI: 1.03-1.25) in multivariable models. Patients with CKD were not more likely to receive SGLT2i therapy (OR 1.07; 95% CI: 0.98-1.16). Patients with increased age (OR 0.77 per 10 years; 95% CI: 0.73-0.80) and lower systolic blood pressure (OR 0.94 per 10mmHg; 95% CI: 0.92-0.96) were less likely to be prescribed SGLT2i. There was substantial facility-level variation of SGLT2i prescription with a median odds ratio (MOR) of 1.81 (1.64-2.03), suggesting a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i. Among patients with HFrEF, 30.7% (2,231/7,263) were prescribed an SGLT2i compared with 26.7% (1,937/7,263) patients prescribed ARNI. Conclusion Although utilization of SGLT2i at the time of discharge is overall low in hospitalized VA patients with HF, SGLT2i prescription rates have increased rapidly compared with ARNI. Opportunities exist to reduce variation in SGLT2i prescription rates in eligible patients across hospitals and to emphasize use in patients with CKD and advanced age.