The Effect of Socioeconomic and Medical Factors on ARNI Prescription Rates

At hospital discharge, low rates of angiotensin receptor-neprilysin inhibitor (ARNI) prescription is associated with multiple socioeconomic and medical factors, according to results of a study published in Circulation: Heart Failure.

Investigators from the University of Arizona sourced data for this retrospective analysis from the Get With The Guidelines -Heart Failure (HF) registry. Patients (N=136,144) discharged from a HF hospitalization between 2017 and 2020 were evaluated for predictors of ARNI prescription. The Distressed Community Index (DCI) database was used to estimate socioeconomic factors.

The study population included patients with a median age of 68 (IQR, 57-78) years, 66.3% were men, 57.7% were White, left ventricular ejection fraction was 25% (IQR, 20%-33%), and 97.3% had comorbidities.

A total of 12.6% of the patients received ARNIs at discharge. Stratified by discharge year, rates had been increasing over time from 8.1% in 2017 to 18.8% in 2020. Among only the subset of patients without an ARNI contraindication, 19.0% received a prescription overall, increasing from 11.4% in 2017 to 30.3% in 2020.

Predictors for receiving an ARNI prescription at discharge included the following:

• Receipt of inpatient ARNIs (odds ratio [OR], 72.091; P <.001)
• Prehospitalization ARNI use (OR, 9.488; P <.001)
• Discharge in 2020 (OR, 2.055; P <.001), 2019 (OR, 1.831; P <.001), or 2018 (OR, 1.378; P <.001) compared with 2017
• Receipt of guideline-directed β-blockers (OR, 1.818; P <.001)
• Receipt of mineralocorticoid receptor antagonists at discharge (OR, 1.773; P <.001)
• End-stage renal disease (OR, 1.418; P =.029)
• Asian (OR, 1.285; P =.041), Hispanic (OR, 1.264; P =.001) or Black (OR, 1.115; P =.026) ethnicity compared with White ethnicity
• Follow-up scheduled at discharge (OR, 1.172; P =.050)

Receipt of an ARNI prescription at discharge was less likely in patients with the following:

• Receipt of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) at discharge (OR, 0.098; P <.001)
• Contraindications for ARNIs, ACE inhibitors, and/or ARBs (OR, 0.113; P <.001)
• Receipt of inpatient inotrope (OR, 0.527; P <.001)
• Hospitalization in a heart transplant center (OR, 0.555; P =.014)
• Discharge to a continued care center (OR, 0.771; P <.001)
• Chronic kidney disease (OR, 0.809; P =.001)
• Distressed compared with prosperous status (OR, 0.813; P =.010)
• Receipt of Medicaid (OR, 0.824; P <.001) or no (OR, 0.597; P <.001) insurance compared with non-Medicare or Medicaid insurance
• Increased age (OR, 0.988; P <.001)

A major limitation of this study is that at least 1 element of the data of interest is missing for nearly all patients (n=110,923), and the missing information was imputed.

This study found that although ARNI prescription at HF hospitalization discharge rates had been increasing, the overall prescription rate remained low. Factors associated with low ARNI distribution included both medical and socioeconomic factors.  “This reinforces the urgent need to ensure patients from distressed communities receive optimum guideline-based care while hospitalized and on discharge,” the study authors wrote.