Understanding the Burden of Heart Failure: Insights from National Data and Healthcare Utilization Patterns in Heart Failure Patients in Germany – Room for Improvement

Background:
Heart failure (HF) is a complex and potentially fatal syndrome characterized by significant morbidity and mortality. However, there is a paucity of recent national data essential for policymakers and healthcare professionals to make informed decisions regarding disease management and resource allocation. Here, we present a secondary analysis of insurance claims data, which aims to investigate the epidemiology, comorbidities, and healthcare utilization patterns of HF patients in Germany.

Methods:
A retrospective real-world analysis was conducted using a representative German claims database to analyze the epidemiological features of HF patients. The longitudinal study utilized anonymized administrative data from 4.5 million individuals from various German Statutory Health Insurance providers (SHIs) between January 1, 2018, and December 31, 2022. This dataset was representative of age, sex, and morbidity, allowing for extrapolation to the entire German SHI population. Epidemiological features of HF patients included disease prevalence, all-cause mortality, comorbidities, and various metrics of healthcare resource allocation. Patients with HF were identified by the disease-defining ICD-10-codes (I50.01, I50.1, I50.5, I11.0, I13.0, I13.2), including HF patients with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF). However, the database does not allow to differentiate between these phenotypes. Medications were analyzed based on the Anatomical Therapeutic Chemical (ATC) codes.

Results:
The annual prevalence of HF was 5.0% in 2018, and patients diagnosed with HF had an average hospitalization rate of 9.1% for HF. In 2022, these numbers were in similar range (prevalence 4.8%, hospitalization rate for HF 9.4%).  All-cause mortality rate within the HF cohort was 9.7% in 2018 and 10.7% in 2022. The average yearly expense increased from 12,477€ per patient in 2018 to 14,530€ in 2022. Notably, in 2022 only 20.1% of patients with HF received a mineralocorticoid receptor antagonist (MRA), and only 17.2% received a sodium glucose cotransporter 2 inhibitor (SGLT2i), with a substantial decrease in the prescription rate of SGLT2i in the elderly (9.9% in patients older than 85 years). Only 7.0% of patients received a comprehensive “four pillar” therapy of SGLT2i, beta-blocker (BB), MRA, and renin-angiotensin system inhibitor (RAASi), despite roughly half of the HF cohort is expected to have HFrEF1.  [Of note:  This study ends in 2022 while guideline recommendations for the use of SGLT2i in HFmrEF and HFpEF were not established before 2023].
Some of the most prevalent comorbidities of HF patients in 2022 were hypertension (93.2%), dyslipidemia (65.2%), coronary heart disease (52.9%), type 2 diabetes mellitus (41.6%), atrial fibrillation and flutter (39.5%), and chronic kidney disease (38.9%).

Conclusion:
This analysis offers a comprehensive overview of HF epidemiology and healthcare management in Germany. The persistently high prevalence of HF and HF-related hospitalization rate, alongside with a low rate of guideline-directed medical therapy indicate a need for targeted interventions to reduce the growing burden of this condition.  These might comprise the support of effective HF management programmes, which are yet to be established for a majority of HF patients in Germany, albeit being strongly recommended by international guidelines.

1) Graziani et al. EurJ Heart Fail 2018