Hospitalization for Acute Heart Failure Provides Opportunities to Intensify Chronic Therapy for Patients with Heart Failure with Reduced Ejection Fraction

Abstract

Introduction: Insurance affects access to care. Data on the impact of coverage on disease progression and mortality in patients with heart failure (HF) and reduced ejection fraction (HFrEF) are limited. Hypothesis: We hypothesized that rates of progression to Stage D HF and mortality among stable outpatients with Stage C HF differ according to type of insurance coverage. Methods: We examined 3-year rates of (1) transition to physician-determined Stage D HF (after accounting for competing mortality) and (2) all-cause mortality in 957 stable outpatients with baseline Stage C HFrEF (index ejection fraction ≤40%) not previously on advanced HF therapies (home inotropes, heart transplant, or mechanical circulatory support [MCS]). All patients received care in an academic center between 1/1/2012 and 3/31/2012 (inception period). Insurance type was classified based on primary payer into Medicare or Medicaid, private, and no insurance. Results: Patient characteristics according to primary payment source are summarized in Table 1. After a median of 3.1 years (1.9-3.2), 112 patients were deemed to have transitioned to Stage D (3-year incidence: 12.3%; annual rate: 4.6%) and 158 died (3-year mortality: 17.7%; annual rate: 6.6%). During follow-up, 42 patients (4.4%) were placed on home inotropes; 21 (2.2%) received MCS; and 7 (0.73%) received heart transplant. In a bivariate comparison, type of insurance did not affect the distribution of advanced therapies (P = .67). In models including income, marital status, demographic and clinical characteristics, type of insurance was not associated with progression to Stage D HF (Table 2). In multivariable models, 3-year mortality was higher among patients with Medicare or Medicaid or no insurance compared to patients with private insurance (Table 2). Conclusion: Among Stage C HFrEF patients receiving care in an academic center, rates of transition to Stage D HF were similar regardless of type of insurance. However, despite similar utilization of advanced HF therapies, mortality was higher among uninsured and Medicare or Medicaid patients. Additional research is needed to identify how to improve access among these patient groups.