Differences in guideline directed medical therapy for rural and non-rural Veterans with heart failure with reduced ejection fraction.
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2025-10
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Abstract
Background
There is a high burden of hospitalizations and deaths annually due to heart failure (HF) in the United States despite effective medical therapy and rural areas may be disproportionately affected. We sought to compare guideline-directed medical therapy (GDMT) utilization between rural and non-rural Veterans with HF with reduced ejection fraction (HFrEF).Methods
We performed a cross sectional cohort study of Veterans with HFrEF (LVEF ≤ 40%) on January 1, 2022. The VA is an integrated health system with reduced financial barriers, which has a high proportion of rural patients. We compared the frequency of medication fills among rural and non-rural Veterans for renin-angiotensin system inhibitors (RASi), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA) and sodium glucose co-transporter 2 inhibitors (SGLT2i). We used a continuous version of the 4-pillar score (C4P) to assess medical therapy intensity. We used multivariable logistic regression to identify patient characteristics associated with a high C4P score.Results
Of 65,025 Veterans with HFrEF, 23,728 (36.5%) resided in a rural location, defined as RUCA (Rural-Urban Commuting Areas) code of greater than 1.1. Compared with non-rural, rural Veterans were more frequently White (82.5% vs 63.9%, P < .01) and had a higher burden of comorbidities. Rural Veterans had longer drive times to primary (32 vs 15 minutes, P < .01) and specialty (74 vs 36 minutes, P < .01) care and were less likely to receive VA Cardiology care (44.4% vs 55.8%, P < .01) or care at a high-complexity (level 1a) VA facility (36.4% vs 50.4%, P < .01). Rural Veterans were less frequently prescribed >50% target dose of RASi (19.9% vs 20.2%, P < .01) and BBs (30.9% vs 32.2%, P < .03) and less frequently prescribed SGLT2i (16.3% vs 18.9%, P < .01) and MRA (27.8% vs 28.6%, P < .03) therapy. Rural Veterans were significantly less likely to have a C4P score in the highest decile (OR 0.94, CI: 0.90-0.99) compared with non-rural Veterans.Conclusion
Rural Veterans with HFrEF were slightly less likely be prescribed comprehensive GDMT. This small difference may be related to gaps in access to VA cardiology and high-complexity facilities. Novel interventions and quality initiatives are needed to decrease disparities in HFrEF care for rural Veterans.Type
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Steverson, Alexandra B, Jun Fan, Natasha Din, Neil Kalwani, Anubodh S Varshney, Aradhana Verma, Hayden B Bosworth, Tomasz Jurga, et al. (2025). Differences in guideline directed medical therapy for rural and non-rural Veterans with heart failure with reduced ejection fraction. American heart journal, 293. p. 107300. 10.1016/j.ahj.2025.107300 Retrieved from https://hdl.handle.net/10161/33901.
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Hayden Barry Bosworth
Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities.
Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.
Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy
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