Temporal and institutional differences in heart failure guideline adherence in Taiwan

BACKGROUND: Guideline-directed medical therapy (GDMT) improves outcomes in heart failure with reduced ejection fraction (HFrEF); however, variations in adherence to guidelines across hospitals and over time remain unknown. We used two Taiwanese national registries to investigate temporal and institutional differences in guideline adherence and outcomes among HFrEF patients. METHODS: We looked at two Taiwanese prospective multicenter cohorts, the TSOC-HFrEF (2013-2014) and TSOC HF 2020 (2019-2022) registries. We looked at adherence to Class I recommended diagnostics and GDMT as well as 1-yr mortality rates. Measured covariates and within-hospital clustering were accounted for using multivariable-adjusted generalized estimating equation models and Cox proportional hazards models, which included marginal models. RESULTS: The study included 3,028 patients with HFrEF from 16 medical centers and four regional hospitals. GDMT prescription and diagnostic testing rates increased significantly between the 2013 and 2020 cohorts (≥2 GDMT classes: 60.4% vs. 86.9%; three GDMT classes: 20.6% vs. 51.6%; both p < 0.001). The adjusted odds ratios for prescribing ≥2 and 3 GDMT classes in 2020 versus 2013 were 4.18 and 3.97, respectively, indicating consistent improvements across hospital types (interaction p-values = 0.721 and 0.467). Patients treated at medical centers had significantly higher prescription rates for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists (39.1% vs. 32.2%, p = 0.011; 62.9% vs. 57.5%, p < 0.001, respectively), while prescription rates for renin-angiotensin system inhibitors were similar across hospital levels (medical center, 71.9% vs. regional hospital, 75.5%, p = 0.179). The 2020 cohort had a significantly lower 1-yr mortality rate (adjusted hazard ratio, 0.75, p = 0.012), with similar survival improvements across medical centers and regional hospitals (interaction, p = 0.106). CONCLUSION: Over time, HFrEF guideline adherence improved significantly at all hospital levels in Taiwan. Improved guideline adherence was associated with a 25% lower risk of all-cause mortality after 1 yr.