Department of Medicine, University of Arizona, Tucson (J.S.T., M.G.L., N.K.S.).
Department of Clinical Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia (A.A.).
Circ Heart Fail. 2022 Nov;15(11):e009395. doi: 10.1161/CIRCHEARTFAILURE.121.009395. Epub 2022 Nov 15.
Angiotensin receptor-neprilysin inhibitor (ARNI) prescription in the United States remains suboptimal despite strong evidence for efficacy and value in heart failure with reduced ejection fraction. Factors responsible for under prescription are not completely understood. Economic limitations may play a disproportionate role in reduced access for some patients.
This is an analysis of the Get With The Guidelines-Heart Failure registry, supplemented with data from the Distressed Community Index. Data were fit to a mixed-effects regression model to investigate clinical and socioeconomic factors associated with ARNI prescription at hospital discharge. Missing data were handled by multilevel multiple imputation.
Of the 136 144 patients included in analysis, 12.6% were prescribed an ARNI at discharge. The dominant determinants of ARNI prescription were ARNI use while inpatient (odds ratio [OR], 72 [95% CI, 58-89]; <0.001) and taking an ARNI before hospitalization (OR 9 [95% CI, 7-13]; <0.001). Having an ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB)/ARNI contraindication was associated with lower likelihood of ARNI prescription at discharge (OR, 0.11 [95% CI, 0.10-0.12]; <0.001). Socioeconomic factors associated with lower likelihood of ARNI prescription included having no insurance (OR, 0.60 [95% CI, 0.50-0.72]; <0.001) and living in a ZIP Code identified as distressed (OR, 0.81 [95% CI, 0.70-0.93]; =0.010). The rate of ARNI prescription is increasing with time (OR, 2 [95% CI, 1.8-2.3]; <0.001 for patients discharged in 2020 as opposed to 2017), but the disparity in prescription rates between distressed and prosperous communities appears to be increasing.
Multiple medical and socioeconomic factors contribute to low rates of ARNI prescription at hospital discharge. Potential targets for improving ARNI prescription rates include initiating ARNIs during hospitalization and aggressively addressing patients' access barriers with the support of inpatient social services and pharmacists.
尽管有强有力的疗效和价值证据表明血管紧张素受体-脑啡肽酶抑制剂（ARNI）可用于射血分数降低的心力衰竭，但在美国，其处方仍不理想。导致处方不足的因素尚不完全清楚。对于一些患者来说，经济限制可能会不成比例地影响他们的药物可及性。
这是对 Get With The Guidelines-Heart Failure 注册研究的分析，并辅以困境社区指数的数据。使用混合效应回归模型来研究与出院时 ARNI 处方相关的临床和社会经济因素。通过多级多重插补处理缺失数据。
在纳入分析的 136144 名患者中，12.6%在出院时被处方 ARNI。ARNI 处方的主要决定因素是住院期间使用 ARNI（比值比[OR]，72[95%置信区间，58-89]；<0.001）和住院前使用 ARNI（OR 9[95%置信区间，7-13]；<0.001）。存在血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂/ARNI 禁忌证与出院时 ARNI 处方的可能性降低相关（OR，0.11[95%置信区间，0.10-0.12]；<0.001）。与 ARNI 处方可能性降低相关的社会经济因素包括没有保险（OR，0.60[95%置信区间，0.50-0.72]；<0.001）和居住在被确定为困境的邮政编码区（OR，0.81[95%置信区间，0.70-0.93]；=0.010）。随着时间的推移，ARNI 处方的比例在增加（OR，2[95%置信区间，1.8-2.3]；与 2017 年相比，2020 年出院的患者处方比例增加<0.001），但在困境社区和繁荣社区之间的处方比例差异似乎在增加。
多种医疗和社会经济因素导致出院时 ARNI 处方率较低。提高 ARNI 处方率的潜在目标包括在住院期间启动 ARNI，并在住院社会服务和药剂师的支持下积极解决患者的药物可及性障碍。
