Inequity of access to ACE inhibitors in Swedish heart failure patients: a register-based study

Abstract

BackgroundSeveral international studies suggest inequity in access to evidence-based heart failure (HF) care. Specifically, studies of ACE inhibitors (ACEIs) point to reduced ACEI access related to female sex, old age and socioeconomic position. Thus far, most studies have either been rather small, lacking diagnostic data, or lacking the possibility to account for several individual-based sociodemographic factors. Our aim was to investigate differences, which could reflect inequity in access to ACEIs based on sex, age, socioeconomic status or immigration status in Swedish patients with HF.MethodsIndividually linked register data for all Swedish adults hospitalised for HF in 2005–2010 (n=93 258) were analysed by multivariate regression models to assess the independent risk of female sex, high age, low employment status, low income level, low educational level or foreign country of birth, associated with lack of an ACEI dispensation within 1 year of hospitalisation. Adjustment for possible confounding was made for age, comorbidity, Angiotensin receptor blocker therapy, period and follow-up time.ResultsAnalysis revealed an adjusted OR for no ACEI dispensation for women of 1.31 (95% CI 1.27 to 1.35); for the oldest patients of 2.71 (95% CI 2.53 to 2.91); and for unemployed patients of 1.59 (95% CI 1.46 to 1.73).ConclusionsAccess to ACEI treatment was reduced in women, older patients and unemployed patients. We conclude that access to ACEIs is inequitable among Swedish patients with HF. Future studies should include clinical data, as well as mortality outcomes in different groups.

Decrease in loop diuretic treatment from 2005 to 2014 in Swedish real-life patients with chronic heart failure

“…We observed lower neuro-hormonal antagonist and β-blocker treatment rates in women and older patients when compared to men and younger patients, respectively. These results are consistent with findings in previous studies on sex- and age-related differences in HF treatment where available data on clinical characteristics and comorbidities could not fully explain the inequities [ 30 , 31 ]. Sex-related differences in neuro-hormonal antagonist and β-blocker treatment have been shown to remain after adjustment for age [ 30 ].…”

Opposite trends in hospitalization and mortality after implementation of a chronic care model-based regional program for the management of patients with heart failure in primary care

“…The impact of HF is even more evident in the elderly, exceeding a 10% prevalence among persons ≥70 years of age [ 8 ]. The prognosis of patients with HF also remains poor, with approximately 50% of patients expected to die within 5 years and with no significant trends towards improvement over the last two decades [ 9 – 12 ]. Moreover, despite the progressive advances in the pharmacological therapy of HF, gaps between guidelines and clinical practice in HF patients are still evident [ 13 ].…”

Inequalities in heart failure care in a tax‐financed universal healthcare system: a nationwide population‐based cohort study

“…Our findings regarding ACEI/ARB and MRA are contrary to previous studies. Two large Swedish studies, 32,33 reporting low income to be associated with a higher ACEI dispensation after hospitalization for HF 32 and a lower rate of MRA prescription among patients with HFrEF and HF duration ≥6 months from the Swedish HF registry, 33 respectively, compared with high‐income patients. Contrary to our results, a UK study including 1802 outpatients with stable HF (LVEF ≤45%) for 3 months, treated with state of the art therapies in cardiology outpatient clinics, found comparable doses of prescribed ACEI/ARB and beta‐blockers across deprivation quintiles 11 .…”

“…Most previous studies have primarily examined prescription or dispensation of ACEI/ARB, beta-blockers, and MRA among patients with HF irrespective of LVEF in hospital, outpatient, and primary care settings. Except for four studies, 11,12,32,33 most previous studies are based on older data collected at a time when patients with HF were not routinely treated with ACEI/ATII-inhibitors, beta-blockers, and MRA. [34][35][36][37][38] Thus, these 'early' studies may not be of relevance to current HF care.…”