Recorded Adoption of SGLT2 Inhibitors from 2022 to 2025 Among Adults with an EHR-Defined HFrEF Phenotype at a Jordanian Public Hospital
Abstract
Background/Objectives: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are foundational therapy for heart failure with reduced ejection fraction (HFrEF), irrespective of diabetes. We evaluated recorded SGLT2i adoption and diabetes-related differences among adults with an electronic health record (EHR)-defined HFrEF phenotype at a Jordanian public hospital. Methods: This retrospective Hakeem cohort included 1750 adults. The frozen HFrEF phenotype was internally validated in an independent non-overlapping sample, and SGLT2i ascertainment was verified by complete-cohort medication review. Comparable annual analyses covered 2022–2025, when medication-source completeness exceeded 90%. Secondary analyses examined first recorded use after a 180-day lookback, concurrent four-class guideline-directed medical therapy (GDMT) in 2025, measured-eGFR threshold cohorts, and prespecified Firth regression among patients with type 2 diabetes (T2DM). Additional sensitivity analyses included a stable four-year cohort, a time-to-first-record analysis with explicit censoring, expanded model diagnostics with a time-to-event sensitivity analysis, and a strict directly documented-coverage GDMT analysis. Results: Sixty-four patients had verified recorded SGLT2i use (3.66%; 95% CI 2.83–4.65). Use was 11.41% (64/561) with T2DM and 0% (0/1189; exact 95% CI 0–0.31) without diabetes. Annual prevalence increased from 0.15% in 2022 to 5.13% in 2025 (absolute increase 4.98 percentage points), while remaining 0% without diabetes. In the stable four-year cohort sensitivity analysis, prevalence similarly increased from 0.21% to 5.34%. In the verified 12-month fixed-horizon cohort, 27/1268 patients (2.13%) had a first recorded use within one year; the 322-day median was conditional on the 50 patients who eventually had a first post-index record and was not interpreted as a cohort-wide waiting time. Only 24/936 patients (2.56%) had all four foundational classes concurrently active in the primary 2025 analysis. The inverse nondialysis-CKD estimate was treated as exploratory because only four treated patients had nondialysis CKD. Conclusions: Recorded adoption improved but remained low and strongly concentrated among patients with T2DM. Multicenter linkage of prescribing, eligibility, dispensing, persistence, and reimbursement data is needed to identify implementation mechanisms.