HF Patient’s Zip Code Telling of Potential Adherence Issues to Meds

Patients living in more disadvantaged neighborhoods were more likely to leave their prescriptions for standard heart failure medications unfilled, retrospective data from a large health system showed.

Among patients with heart failure with reduced ejection fraction (HFrEF), there was a trend of higher rates of nonadherence to guideline-directed medical therapy (GDMT) with lower neighborhood-level socioeconomic status (SES) that persisted after adjustment for clinical characteristics:

• Quartile 4: 40% (reference group, highest neighborhood SES)
• Quartile 3: 41.5% (OR 1.05, 95% CI 0.91-1.23)
• Quartile 2: 47.5% (OR 1.35, 95% CI 1.16-1.56)
• Quartile 1: 51.7% (OR 1.57, 95% CI 1.35-1.83)

“Our findings highlight an important inequity in HFrEF treatment, reveal a key risk factor for medication nonadherence, and underscore the importance of considering neighborhood-level disparities when developing initiatives to improve medication adherence,” reported researchers led by Amrita Mukhopadhyay, MD, of NYU Grossman School of Medicine, New York City, in JAMA Network Open.

Maintaining patient adherence to GDMT is an established challenge in heart failure clinics, despite these medications reducing mortality and hospitalization when taken as directed.

The pillars of GDMT for heart failure are beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and SGLT2 inhibitors.

Mukhopadhyay and co-authors noted that the observed relationship between neighborhood SES and medication nonadherence in their report was not affected by race, neighborhood access to transportation, and neighborhood pharmacy density. Walkability showed only a little mediation of effect, with higher walkability somewhat more protective in the lowest two neighborhood SES quartiles.

“Therefore, although increasing pharmacies, adding transportation routes, and improving walkability likely has benefits, these efforts are probably insufficient to address nSES [neighborhood SES] disparities in medication nonadherence,” the researchers suggested.

“Overall, the association between nSES and medication nonadherence is likely multifaceted and due to complex, dynamic interactions between environmental, individual, and cognitive factors,” the group wrote. “Beyond neighborhood-level factors, associated individual-level factors could include medication cost, income, family support, health literacy, healthcare interactions, language, and individual beliefs.”

In a press release, study co-author Saul Blecker, MD, also at NYU Langone, said the “results support targeting interventions that have already been shown to improve medication adherence, such as patient education programs and frequent follow-up with healthcare professionals, for those living in the most at-risk areas.”

The retrospective cohort study was conducted from 2020 to 2021 at Mukhopadhyay’s institution, a large urban health system. Investigators had clinical, pharmacy, and demographic data gathered from the hospital’s electronic health record and identified 6,247 adults with HFrEF who had been prescribed at least one GDMT.

Mean age was 73 years, and 69.5% were men. By race, the cohort was 62.9% white, 16.2% Black, and 11.8% Hispanic. Over 55% were listed as living in New York City.

Based on the patients’ given address, each person’s neighborhood-level SES was calculated using the Agency for Healthcare Research and Quality SES index that takes into account census-tract level measures of poverty, rent burden, unemployment, crowding, home value, and education.

Lower neighborhood SES areas were associated with lower access to transportation and pharmacy density but higher walkability.

Based on prescription fills, medication nonadherence was defined as the proportion of days covered <80% over 6 months, averaged across GDMT medications.

Study authors cautioned that pharmacy fills may not accurately capture actual adherence to medication. They also acknowledged that “important confounders may be unmeasured or missing” in their analysis, for example neighborhoods changing over time and patients moving between neighborhoods.

“Our finding of higher rates of medication nonadherence for patients with HFrEF living in lower nSES neighborhoods was consistent with observations in other diseases or conditions, including cardiovascular disease prevention, diabetes, and chronic kidney disease,” Mukhopadhyay and colleagues nevertheless noted.

With the overarching goal of identifying individual patients at highest risk for not taking their heart failure medications, co-author Samrachana Adhikari, PhD, also at NYU Langone, added in a statement that the researcher group next plans to examine the effects of out-of-pocket medication cost, differences in insurance policy coverage, and pharmacy hours.

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