Out-of-Pocket Costs Influence GDMT Uptake in Heart Failure, with Anand Shah, MD, MBA


Anand Shah, MD, MBA, provides insights into a study he led examining the impact of out-of-pocket costs and insurance type on uptake of GDMT in patients with heart failure with reduced ejection fraction.

Anand Shah, MD, MBA | Credit: LinkedIn

Anand Shah, MD, MBA
Credit: LinkedIn

An analysis from investigators at the Duke University Medical Center and the University of North Carolina at Chapel Hill School of Medicine offers new insight into the impact of out-of-pocket costs with optimal uptake of guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF).

Presented at the Heart Failure Society of American 2023 Annual Scientific Meeting, results of the study, which was a preplanned potshot analysis of a pilot study for patients admitted to noncardiology services, suggests a virtual consult intervention to improve GDMT prescribing was generally effective only when out-of-pocket monthly medication costs did not exceed $100, but investigators noted this interaction was no statistically significant.

Per study design, the population for the analysis included patients in the trial intervention arm, who were subject to a virtual consult with a certified pharmacy technician who would provide cost estimates of contemporary GDMT when available and completed insurance prior authorizations required. The primary outcomes of interest for the study were change in modified heart failure optimal medical therapy (OMT) score based on GDMT use and target dosing from admission to discharge according to insurance status and out-of-pocket costs.

Upon analysis, results provided evidence of significant variability by insurance type for both median monthly out-of-pocket costs and for change in OMT score from admission to discharge. Investigators pointed out change in OMT score demonstrated a modest and nonsignificant positive trend with lower expected monthly costs for contemporary GDMT.

For more on the study, its origins, the findings, and how this data can be leveraged by clinicians in real-world settings, HCPLive Cardiology reached out to study presenter Anand Shah, MD, MBA, cardiology and preventive medicine fellow at the University of North Carolina at Chapel Hill School of Medicine.

HCPLive Cardiology: Can you take us behind why this would be included as a preplanned posthoc analysis?

Shah: I think part of the background leading up to this was we know there are the four pillars of guideline-directed medical therapy for heart failure and that patients should be on these drugs. Unfortunately, in clinical practice, the number of patients actually on these medications is shockingly low. So, there's this huge gap between patients that don't have these medications and those that we know would benefit from it. Obviously, there are a lot of clinical characteristics that determine whether a patient qualifies or not, but I think an area that we wanted to really explore was the financial component, especially with a few of the categories, particularly with SGLT2 inhibitors and the new ARNIs, which are all patent protected. We wanted to see if cost really plays a variable and whether patients could be on these medications or not right now.

HCPLive Cardiology: What were the primary findings of your study?

Shah: The findings from this study provide a big-picture perspective. Among patients whose expected monthly medication costs were less than $50 or less than $100, there was a higher likelihood of them receiving guideline-directed medical therapy. It's important to note that this analysis was pre-planned and ad hoc, based on a prior study that has already been published.

The previous study focused on patients admitted to non-cardiology services in the hospital, specifically those with a history of heart failure and reduced ejection fraction. These patients were randomly assigned to one of two groups: one received a virtual consultation from a multidisciplinary heart failure team, which recommended optimization of GDMT based on clinical factors and medical history, while the other group did not receive this intervention. In our study, we examined the patients in the intervention group who received the virtual consultation. As part of this consultation, we provided estimated out-of-pocket monthly costs for GDMT medications, particularly those related to pattern protectors.

We then analyzed changes in prescribing patterns from admission to discharge, stratifying the data based on expected out-of-pocket monthly costs. We aimed to determine the extent of change in the prescription of guideline-directed medical therapy. The results of our analysis showed a trend toward increased GDMT optimization from admission to discharge for patients with lower out-of-pocket monthly costs. Unfortunately, these results did not reach statistical significance. This may be attributed, in part, to the relatively small sample size, which limited some of the statistical analyses in this context.

This transcript was edited for grammar and clarity using artificial intelligence.


  1. Shah A, Mentz RJ, Cline C, et al. Impact of Cost Evaluations in Heart Failure. Paper presented at: Heart Failure Society of America 2023 Annual Scientific Meeting; October 6 - 9; Cleveland, OH. Accessed October 7, 2023.
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