Addison, Daniel

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline directed medical therapy. Objective: To study the association between median annual household income and: (1) odds of receiving sacubitril/valsartan, a novel angiotensin receptor/neprilysin inhibitor (ARNI) therapy among insured patients with heart failure with reduced ejection fraction (HFrEF) and (2) medication adherence (measured as the proportion of days covered (PDC)). Hypothesis: lower income is associated with lower odds of receiving and adhering to ARNI among patients with HFrEF. Methods: Using Optum’s deidentified Clinformatics® Data Mart, patients with ≥ 2 diagnoses of HFrEF and ≥ 6 months of enrollment for follow up (2016-2020) were included. Covariates included age, race, ethnicity, sex, educational attainment, household net worth, geographical region and Elixhauser comorbidity index. Prescription for ARNI was defined by presence of a claim within 180 days. Adherence was defined as PDC ≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. We also assessed for race-income interaction. Results: Among 322007 individuals with HFrEF diagnosis, 136,613 had ≥6 months of complete data. Of the patients eligible for ARNI, only 5.4% (7409/136613) received a claim within 180 days of HFrEF diagnosis. After adjusting for social and clinical factors, the odds were elevated for ARNI claim within 180 days of HFrEF diagnosis (OR=1.38, 95% CI: 1.27, 1.49) for the highest income category (>$100K) compared with the lowest (<$40K). After adjustment, income <$40k) was associated with a 47% higher odds of PDC<80% compared with income >$100K. Conclusions: Higher patient income is associated with increased likelihood of an ARNI claim within 180 days of HFrEF diagnosis, even after adjusting for socioeconomic and clinical factors. Future analyses are needed to determine other social factors associated with delay in ARNI initiation and long-term adherence.