Multimorbidity in heart failure: real world burden, treatment gaps, and healthcare utilization in germany
J Mueller-Ehmsen, S Stoerk, M Schultze, M Mueller, N Schulte, E Ziegler, C A Schneider, S Von HaehlingAbstract
Background
Heart failure (HF) commonly coexists with chronic kidney disease (CKD) and type 2 diabetes (T2D), amplifying morbidity, mortality, hospitalizations, and healthcare utilization. Although sodium–glucose cotransporter-2 inhibitors (SGLT2i) provide consistent benefits across HF, CKD, and T2D and are guideline-recommended, their real-world uptake in Germany remains limited. We characterized contemporary treatment patterns—focusing on SGLT2i prescriptions—and quantified clinical and economic burden among multimorbid HF patients using nationwide statutory health insurance (SHI) claims.
Methods
We performed a retrospective analysis of anonymized German SHI claims (~4.5 million insured; January 2018–December 2023), representative by age, sex, and morbidity, with extrapolation to the German population. HF was identified via ICD-10 codes (I50 terminal, I50.01, I50.1, I50.9, I11.0, I13.0, I13.2). Differentiation by ejection fraction (HFrEF, HFmrEF, HFpEF) was not possible. Prescriptions were captured using ATC codes. Outcomes included medication use, comorbidity prevalence, physician visits, costs, days of illness, HF-related hospitalization, and all-cause mortality
Results
In 2023, an estimated 1,704,382 individuals (2.0% of 83.5 million) had HF alone (without CKD or T2D); 1,491,612 (1.8%) had HF+CKD; 1,668,961 (2.0%) had HF+T2D; and 796,377 (1.0%) had the triad HF+CKD+T2D. SGLT2i use was 13.9% in HF alone, 33.6% in HF+CKD, 39.4% in HF+T2D, and 42.9% in HF+CKD+T2D. Patients with HF+CKD+T2D averaged 15.5 physician visits/year versus 12.4 in HF alone; mean annual costs were €22,933 vs €11,814; and days of illness 103.6 vs 68.3. Coronary heart disease (63.7% vs 44.8%) and obesity (47.9% vs 24.7%) were more prevalent in the multimorbid group. HF-related hospitalization occurred in 16.8% of HF+CKD+T2D vs 5.4% of HF alone; all-cause mortality was 15.8% vs 7.1%.
Conclusion
Multimorbidity in HF in Germany is associated with substantially higher clinical and economic burden. Despite robust evidence and guideline recommendations, SGLT2i utilization remains far below expectations, revealing a persistent evidence-to-practice gap. The excess hospitalization and mortality among patients with combined HF, CKD, and T2D highlight the need for integrated, cross-sectoral care pathways and systematic implementation of evidence-based therapies to improve outcomes in this high-risk population.