Background:
Heart failure (HF) frequently coexists with major comorbidities such as chronic kidney disease (CKD) and diabetes mellitus (T2D), compounding morbidity, mortality, hospitalizations, and healthcare resource utilization. Although sodium-glucose cotransporter-2 inhibitors (SGLT2i), have shown robust clinical benefits across these populations, their real-world adoption in Germany remains limited. We sought to investigate contemporary treatment patterns, with a specific focus on SGLT2i prescription, and quantified the clinical and economic burden among multimorbid HF patients using nationwide statutory health insurance (SHI) claims data.
Methods:
We conducted a retrospective analysis of anonymized German SHI claims covering approx. 4.5 million individuals (January 2018–December 2023), representative of the national population by age, sex, and morbidity, with extrapolation to the German population. Subjects were insured by various German statutory health insurance providers. HF patients were identified by ICD-10 codes (I50 terminal, I50.01, I50.1, I50.9, I11.0, I13.0, I13.2), which encompassed patients with reduced, mildly reduced, or preserved ejection fraction (HFrEF, HFmrEF, HFpEF), though differentiation between these phenotypes was not possible. Prescription data was analyzed according to Anatomical Therapeutic Chemical (ATC) codes.
Results:
In 2023, an estimated 1,704,382 individuals (2.0% of the German population, 83.5 million) were diagnosed with HF alone (HF with neither CKD, nor T2D); 1,491,612 (1.8%) with HF and CKD; 1,668,961 (2.0%) with HF and T2D; and 796,377 (1.0%) with the triad of HF, CKD, and T2D – representing the most severely ill subgroup. SGLT2i use was 13.9% in HF alone, 33.6% in HF+CKD, 39.4% in HF+T2D, and 42.9% in HF+CKD+T2D. Patients with HF+CKD+T2D averaged 15.5 physician visits/year versus 12.4 in HF alone; mean annual costs were €22,933 vs €11,814, with 103.6 vs 68.3 days of illness. Coronary heart disease (63.7% vs 44.8%) and obesity (47.9% vs 24.7%) were more prevalent in the multimorbid group. HF-related hospitalization occurred in 16.8% of HF+CKD+T2D versus 5.4% in HF alone; all-cause mortality was 15.8% vs 7.1%.
Conclusion:
Multimorbidity among HF patients in Germany is associated with a markedly higher clinical and economic burden. Despite the proven efficacy of SGLT2i, their utilization remains far below guideline recommendations, highlighting a persistent gap between evidence and practice. The excess hospitalization and mortality risk in patients with combined HF, CKD, and T2D underscores an urgent need for integrated cross-sectoral care models and systematic implementation of evidence-based therapies to improve outcomes in this high-risk population.
