Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients

Abstract

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

Dissecting the causal relationship between household income status and genetic susceptibility to cardiovascular-related diseases: Insights from bidirectional mendelian randomization study

“…Moreover, they neglect necessary health maintenance behaviors, such as annual medical checkups or adherence to secondary prevention medications. This may result in a worse prognosis of myocardial infarction and likely development of heart failure [ 34 – 36 ]. On the other hand, patients with heart failure have limited mobility to various degrees or disabilities in daily work that cause their income and quality of life to decline.…”

Association Between Copayment Amount and Filling of Medications for Angiotensin Receptor Neprilysin Inhibitors in Patients With Heart Failure

“…Prior studies have found that high copayments differentially affect patients with lower income 11 , 12 , 36 , 37 and that patients with lower income are less likely to fill prescriptions for ARNI. 16 In our sample, we expected patients living in neighborhoods with low SES index to have greater risk of copayment‐related decreases in adherence. However, we found the opposite interaction, where patients living in high SES index neighborhoods were actually more likely to be nonadherent when faced with high copayments as compared with patients living in low SES index neighborhoods, who had more similar rates of nonadherence for all copayment groups.…”

“…For example, a recent study found that lower household income was associated with lower adherence to ARNI. 16 Such inequities could be exacerbated by copayments, and whether the association between copayment and adherence varies for certain subgroups is poorly understood.…”

Neighborhood-Level Socioeconomic Status and Prescription Fill Patterns Among Patients With Heart Failure

“…11 Moreover, nSES may be associated with individuallevel SES factors, such as income or medication cost, both of which have been associated with nonadherence to GDMT for HFrEF. [12][13][14][15] Because individual-level SES information may not always be readily available, identifying neighborhood-level risk factors for medication nonadherence could play a key role in informing community-based and policy-level interventions to improve medication adherence. Therefore, we aimed to assess the association between nSES and medication nonadherence to GDMT for patients with HFrEF.…”