Differences in guideline directed medical therapy for rural and non-rural Veterans with heart failure with reduced ejection fraction

Abstract

Background: There is a high burden of hospitalizations and deaths annually due to heart failure (HF) in the United States despite effective medical therapy and rural areas may be disproportionately affected. We sought to compare guideline-directed medical therapy (GDMT) utilization between rural and non-rural Veterans with HF with reduced ejection fraction (HFrEF).

Methods: We performed a cross sectional cohort study of Veterans with HFrEF (LVEF ≤ 40%) on January 1, 2022. The VA is an integrated health system with reduced financial barriers, which has a high proportion of rural patients. We compared the frequency of medication fills among rural and non-rural Veterans for renin-angiotensin system inhibitors (RASi), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA) and sodium glucose co-transporter 2 inhibitors (SGLT2i). We used a continuous version of the 4-pillar score (C4P) to assess medical therapy intensity. We used multivariable logistic regression to identify patient characteristics associated with a high C4P score.

Results: Of 65,025 Veterans with HFrEF, 23,728 (36.5%) resided in a rural location, defined as RUCA (Rural-Urban Commuting Areas) code of greater than 1.1. Compared with non-rural, rural Veterans were more frequently White (82.5% vs 63.9%, P < .01) and had a higher burden of comorbidities. Rural Veterans had longer drive times to primary (32 vs 15 minutes, P < .01) and specialty (74 vs 36 minutes, P < .01) care and were less likely to receive VA Cardiology care (44.4% vs 55.8%, P < .01) or care at a high-complexity (level 1a) VA facility (36.4% vs 50.4%, P < .01). Rural Veterans were less frequently prescribed >50% target dose of RASi (19.9% vs 20.2%, P < .01) and BBs (30.9% vs 32.2%, P < .03) and less frequently prescribed SGLT2i (16.3% vs 18.9%, P < .01) and MRA (27.8% vs 28.6%, P < .03) therapy. Rural Veterans were significantly less likely to have a C4P score in the highest decile (OR 0.94, CI: 0.90-0.99) compared with non-rural Veterans.

Conclusion: Rural Veterans with HFrEF were slightly less likely be prescribed comprehensive GDMT. This small difference may be related to gaps in access to VA cardiology and high-complexity facilities. Novel interventions and quality initiatives are needed to decrease disparities in HFrEF care for rural Veterans.