(B-029) Predictors of initiation, adherence, and persistence to guideline-directed medical therapy following heart failure hospitalizations

Background: Heart failure (HF) is a leading cause of US hospitalizations. Standard HF pharmacotherapies, termed guideline-directed medical therapy (GDMT), consist of 4 prescription medication classes. There are limited data regarding use of GDMT following hospitalization.

Objectives: To describe rates and predictors of primary non-adherence, initiation, adherence, and persistence to GDMT following HF hospitalization.

Methods: Retrospective cohort study of electronic health records from a 40-hospital US health system. We included adults hospitalized for HF for ≥2 days and discharged home between 7/2017-3/2023. We measured GDMT as treatment with beta-blockers (BBs), renin-angiotensin-aldosterone system inhibitors (RAASs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter 2 inhibitors (SGLT2s). For each GDMT class, we defined initiation as a new fill within 7 days post-discharge and primary non-adherence as a discharge prescription order without a corresponding fill. We defined adherence at 6 months as proportion of days covered (PDC) ≥80% and persistence as continuous days’ supply at 6 months with 45 day grace periods. We used LASSO regression to identify clinical, sociodemographic, and hospitalization factors associated with GDMT prescription, primary non-adherence, initiation, adherence, and persistence.

Results: The cohort included 3867 HF patients (age 71±14 years, 35% female, 85% White, 15% Black). The proportion of patients using all recommended GDMT increased from 4% on admission to 14% on discharge. At admission, 49%, 38%, 10%, and 3% were using BBs, RAASs, MRAs, and SGLT2s, respectively, and upon discharge, GDMT use increased by 39%, 36%, 1%, and 1%, respectively. In total, 42% of the cohort were prescribed ≥1 new GDMT class, yet 28% of those prescribed a new GDMT class did not fill ≥1 new prescription.

At 6 months post-discharge, 66% were adherent and 42% were persistent to all discharge GDMT medications. Median [IQR] PDC across GDMT classes was 99 [66, 100]. Baseline GDMT use was associated with lower likelihood of GDMT prescription, initiation, adherence, and persistence. Baseline SGLT2i use and dementia were associated with higher likelihood of primary non-adherence. Private insurance was associated with lower likelihood of primary non-adherence, but higher likelihood of initiation, adherence, and persistence. Delirium was associated with higher likelihood of adherence and persistence.

Conclusions: In the six months following HF hospitalization, over half of patients were non-adherent and non-persistent to GDMT and ~25% did not initiate prescribed GDMT. These results emphasize the importance of supporting and monitoring HF patients’ medication use beyond the initial prescription of GDMT.