Abstract P156: Insurance Impact on Guideline-Directed Medical Therapy Prescription in HIV Heart Failure Patients: Past vs. Present Data From New York City's Largest Public Healthcare System
Authors: Chen Yi-Yun , Borkowski Pawel , Nazarenko Natalia , Parker Matthew , Biavati Luca , Vargas-Pena Coral , Chowdhury Ishmum , Bock Joshua , Faillace Robert , Palaiodimos Leonidas 
Published: May 2024

Introduction:
Guideline-Directed Medical Therapy (GDMT), comprising renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors, and sodium glucose cotransporter 2 inhibitors, significantly enhances patient survival in heart failure cases. However, the impact of public insurance, private coverage, and being uninsured on GDMT for HIV heart failure patients is understudied. This research compares GDMT prescriptions across various insurance types over time.

Method:
This study analyzed data from the New York City Health + Hospitals HIV Heart Failure (NYC 4H) retrospective cohort, comprising records from eleven major NYC Health + Hospitals. Patients were recruited from hospital visits, both inpatient and clinic, spanning from July 2017 to June 2022. Follow-up records were reviewed between July 2022 and August 2023. Insurance types were determined based on primary insurance coverage in the medical charts. Guideline-directed medical therapy (GDMT) was reviewed at baseline and follow-up encounter. Insurance coverage and GDMT prescriptions were compared using chi-square tests. Multivariable logistic regression models, adjusted for age, sex, race, and co-morbidities, were employed to observe the association between insurance and GDMT prescriptions.

Result:
A total of 726 HIV heart failure patients participated in the study, including 263 with Medicare, 334 with Medicaid, 96 with private insurance, and 33 without insurance. Significant difference in GDMT prescriptions were evident at baseline, with >1 and >2 GDMT prescriptions being higher among uninsured (69.7% and 36.4%) and Medicare (66.2% and 37.6%) patients compared to Medicaid (54.8% and 29.9%) and private insurance patients (55.2% and 20.8%) (P<0.05). Private insurance holders exhibited a 49% lower likelihood of receiving >2 GDMT prescriptions than Medicare beneficiaries after adjusting for age, sex, race, and co-morbidities (adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] [0.28, 0.93], p<0.05). Over the four-year follow-up, prescription rates for GDMT medications notably increased. However, disparities persisted in >1 and >2 GDMT prescriptions across insurance types, including 90.9% and 51.5% for uninsured, 76% and 48.3% for Medicare, 72.8% and 45.2% for Medicaid, and the lowest rates of 66.7% and 35.4% for private insurance patients, respectively (P<0.05). After adjusting for covariates, no statistically significant differences in GDMT prescriptions were found across insurance type.

Conclusion:
GDMT prescriptions significantly improved over the follow-up period within HIV heart failure population. Although the differences diminished slightly, private insurance beneficiaries consistently exhibited the lowest GDMT prescription rates at both baseline and follow-up, in comparison to Medicare, Medicaid, and the uninsured population.