Journal of Investigative Medicine · Nov 3, 2026
EXPRESS: Age, Insurance, and Social Vulnerability as Determinants of Sodium-Glucose Cotransporter 2 Inhibitor After New-Onset Heart Failure: Insights from Epic Cosmos
By Shukla K, Sinha M, Potlach T et al.
Background: Social determinants of health contribute to inequities in heart failure (HF) management, yet how age, insurance status, and social vulnerability index (SVI) jointly influence sodium–glucose cotransporter 2 inhibitor (SGLT2i) use remains poorly understood. Objective: To evaluate how SVI and key demographic and system-level factors impact SGLT2i initiation following new-onset HF. Methods: This retrospective cohort study used the Epic Cosmos, a national, de-identified electronic health record repository. Adults aged ≥18 years hospitalized with a new HF diagnosis between 2021 and 2024 were included, excluding those with prior SGLT2i use, dialysis-dependent kidney disease, or hospice enrollment. SVI was categorized into quartiles from least vulnerable (Q1) to most vulnerable (Q4). The primary outcome was SGLT2i initiation following index HF hospitalization stratified by SVI, age, and insurance types. Secondary outcomes included crude and age-adjusted mortality. Results: Among 389,986 patients hospitalized with new HF, 81,387 patients (20.9%) were started on SGLT2i. Higher social vulnerability was inversely associated with initiation (Q4 vs Q1 adjusted OR 0.96, 95% CI 0.93–0.98). Younger age was the strongest predictor of initiation (<45 vs 65–74 years: adjusted OR 1.53, 95% CI 1.48–1.59). Commercial insurance was independently associated with higher initiation odds (adjusted OR 1.20, 95% CI 1.18–1.22; p<0.001), as was Medicaid beneficiaries (adjusted OR 1.06, 95% CI 1.02–1.11; p=0.006). Conclusion: In patients with new HF diagnosis, a persistent disadvantage in SGLT2i initiation exists in high-SVI communities. Age and insurance, not social vulnerability alone, are the dominant determinants, highlighting the need for targeted strategies in older adults and payer-level reform.