GDMT Underused for Heart Failure in Underserved FQHC Population

Guideline-directed medical therapy (GDMT) remains significantly underused among patients with heart failure (HF) treated at a federally qualified health center (FQHC) serving a predominantly low-income, uninsured population, according to a study published in Cureus.¹

“To our knowledge, this is one of the few studies to evaluate GDMT prescribing patterns specifically within an FQHC serving a predominantly low-income and uninsured urban population, filling an important gap in the existing literature,” wrote the researchers of the study. “Our findings are consistent with those from larger registries.”

The retrospective cross-sectional study reviewed charts of 50 patients with HF treated between May 2022 and May 2024. Patients were classified according to the study's echocardiographic criteria as having HF with an ejection fraction (EF) below 50% or HF with preserved EF (HFpEF; > 50%). Although current guidelines distinguish HF with reduced EF (HFrEF; < 40%) from HF with mildly reduced EF (41%- 49%), the investigators analyzed patients with EF below 50% as a single group

Prescribing Gaps Persisted Across Drug Classes

Among patients with HFrEF, 93% were prescribed β-blockers, and 83% were prescribed angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNIs). Far fewer received mineralocorticoid receptor antagonists (MRAs; 29%) or sodium-glucose cotransporter 2 (SGLT2) inhibitors (34%). Prescribing patterns were similar for patients with HFpEF, with one notable exception: none of the patients with HFpEF received an SGLT2 inhibitor (P = .05)

Patients with HFpEF were also significantly older on average than those with HFrEF (68 vs 58 years; P = .02), consistent with the established epidemiology of the 2 phenotypes.

Notably, approximately 72% of the study population was uninsured, a detail the authors said is central to interpreting the prescribing gaps observed.

Authors Discuss Potential Contributors

The authors pointed to medication affordability as a key barrier, even for generic GDMT agents. They noted that as of 2018, the average annual Medicare cost for carvedilol, lisinopril, and spironolactone combined was $173, including about $64 in out-of-pocket spending, figures that may still be prohibitive for very-low-income patients despite some pharmacies offering 90-day generic supplies for as little as $10. By contrast, newer agents such as sacubitril-valsartan and dapagliflozin can carry annual list prices exceeding $10,000, a burden the authors said falls hardest on uninsured patients.

Beyond cost, the study authors cited limited health literacy and medical mistrust, particularly within Black communities, where historical injustices in research and care delivery have contributed to reduced engagement in both clinical care and research participation as compounding factors. Limited access to specialists and multidisciplinary HF teams was also raised as a likely contributor.

The authors situated their findings alongside the CHAMP-HF registry, noting that the registry found among eligible patients, 27% of patients with HFrEF were not prescribed ACE inhibitor/ARB/ARNI therapy, 33% were not receiving β-blockers, and 67% were not receiving MRAs, underscoring that underuse of GDMT is not unique to safety-net settings, even as this study is among the first to characterize prescribing specifically within an FQHC population.

The authors acknowledged several limitations. The small sample size—particularly the HFpEF group (n = 9)—limited statistical power. The study also could not determine why medications were withheld, as the retrospective design did not capture whether gaps reflected clinical contraindications, patient refusal, or prescriber decisions. As a single-center study, generalizability to other FQHCs is also limited.

These findings track with broader national data. Registry and guideline analyses show that fewer than 1 in 5 eligible patients leave the hospital on all 4 GDMT drug classes, with uptake varying by insurance status and documented social needs, gaps that disproportionately affect patients in safety-net systems.² Prior authorization delays further compound underuse, and retail prices commonly exceed $500 to $700 per month for SGLT2 inhibitors and sacubitril-valsartan, out-of-pocket burdens that disproportionately affect low-income and minority patients and contribute to physician inertia.

Taken together, these findings suggest health plans and systems serving Medicaid and uninsured populations may need to move beyond provider education alone. Building electronic health records order sets that auto-trigger preferred formulary options, prior authorization templates, and manufacturer assistance links, paired with team-based, equity-focused care models using advanced practice providers, represents a concrete operational lever payers could support to close the GDMT gap alongside financial counseling and care coordination investments.

“Our findings provide local implementation evidence consistent with the broader literature, suggesting that GDMT remains substantially underutilized among underserved patients receiving care at an FGHC, with particularly low prescribing rates observed for MRAs and SGLT2 inhibitors,” wrote the researchers. “Financial barriers, lack of insurance coverage, limited health care access, and broader social determinants of health may contribute to these disparities; however, because these variables were not directly measured in our study, they remain plausible hypotheses warranting further investigation.”

References

1. Ehinmisan AO, Jain-Aggarwal S, Karki S. Gaps in guideline-directed medical therapy for heart failure: a cross-sectional study in an underserved population. Cureus. 2026;18(6):e111419. doi: 10.7759/cureus.111419
2. Health equity in HF: strategies to improve GDMT access in underserved populations with APPs. American College of Cardiology. May 1, 2026. Accessed June 26, 2026. https://www.acc.org/latest-in-cardiology/articles/2026/05/01/01/online-exclusive-health-equity-in-hf