Sex-specific differences in heart failure care in Germany: real-world evidence from claims data

Background Heart failure (HF) imposes substantial burden in terms of mortality, morbidity, and impaired quality-of-life. Sex-specific differences in pathophysiology, pharmacodynamics, and hormonal/genetic factors influence aetiology, clinical presentation, therapeutic response and outcomes, but these aspects remain under-recognised, partly due to limited female representation in clinical trials. Sex-related patterns in real-world HF care are not fully elucidated. Objective To describe sex-specific differences in clinical characteristics, treatment patterns, diagnostics, and healthcare utilisation in a nationwide German HF population. Methods We conducted a retrospective analysis of anonymised German statutory health insurance claims for 2023. The dataset included ~4.5 million insured individuals and was representative by age, sex, and morbidity, allowing extrapolation to the national population. HF was identified by ICD10 codes (I50 terminal codes; I50.01, I50.1, I50.9, I11.0, I13.0, I13.2). Ejection fraction subtypes were unavailable. Prescriptions were captured via ATC codes. Outcomes included guideline-directed medical therapy (GDMT) utilisation, comorbidities, ambulatory diagnostics, specialist visits, healthcare costs per patient, and sick days, analysed by sex strata. Comparisons were descriptive and unadjusted. Results In 2023, 25.9% of HF patients received an SGLT2 inhibitor and 10.0% received all four GDMT pillars, although epidemiological data suggest that approximately half of patients may have HFrEF. Compared with men, women had lower prescriptions of SGLT2i (20.0% vs 31.1%), RAS inhibitors (68.2% vs 73.5%), betablockers (67.4% vs 69.1%), and MRAs (20.6% vs 28.1%), but higher diuretic use (60.2% vs 55.7%). Four pillar therapy was less frequent in women (6.7% vs 13.1%). Comorbidities differed by sex, with large disparities in thyroid disease (47.4% women vs 23.6% men; Δ 23.8) and coronary artery disease (43.7% women vs 62.3% men; Δ 18.6). Myocardial infarction, cardiovascular disease, and sleep apnoea were more prevalent in men (25.1% vs 12.2%; 76.2% vs 63.5%; 17.0% vs 8.4%), while depression was more prevalent in women (31.3% vs 18.9%). Healthcare utilisation also differed: fewer women had ≥ 1 cardiology visit (36.6% vs 48.1%) and ambulatory diagnostics were less frequent (NT-proBNP 16.3% vs 17.1%; echocardiography 34.1% vs 43.9%). Mean sick days per patient were lower in women (70.3 vs 77.1), as were total annual healthcare costs (28.6 vs 36.7 billion €). Conclusions In this nationwide real-world analysis, substantial sex-related disparities exist in GDMT utilisation, comorbidities, diagnostic evaluation, specialist care, and costs among HF patients in Germany. Women were less likely to receive SGLT2i and four pillar therapy and underwent fewer cardiology visits and diagnostic tests. Our findings highlight important gaps in equitable HF care and indicate potential for improving GDMT implementation in women.