Background
Heart failure is common and highly morbid in older adults. Performance measurement systems for this condition may work best when they account for the reasons why physicians do not provide guideline-recommended interventions.
Objective
To develop a conceptual framework for understanding the proximate, patient-centered reasons why physicians do not prescribe ACE inhibitors and beta blockers to patients with heart failure.
Design
Focus group study using a two-stage design. First, we asked participants to describe reasons for not prescribing ACE inhibitors and beta blockers to patients with heart failure and impaired ejection fraction. Second, we asked groups to develop concept maps that organized these reasons into categories and described the relationships between these categories.
Participants
Seven focus groups comprising 31 academically-affiliated clinicians of different specialties and levels of training. Participants were recruited via invitations sent to clinicians within each target group.
Approach
We synthesized each group’s concept maps to develop a consensus scheme for categorizing reasons for non-prescribing.
Results
We identified two broad themes. First, clinicians hinted at their own attitudinal barriers to prescribing. However, they framed their comments largely around patient-centered reasons for non-prescribing that arose in individual patient encounters. Second, decision-making about heart failure drug therapy often involved a complex and overlapping series of considerations. Five categories of reasons for not prescribing ACE inhibitors and beta blockers emerged: 1) adverse effects of drug therapy, 2) non-adherence to therapeutic and monitoring plan, 3) patient preferences and beliefs, 4) co-management and transitions of care, and 5) prioritization and patient benefit.
Conclusions
Physician reasons for not prescribing guideline-recommended drugs for heart failure are complex but can be organized into a useful taxonomy. This taxonomy may be helpful for performance measurement and quality improvement programs that seek to understand and account for reasons for physician non-adherence to guidelines.
Brand-name terminology is commonly used and decreases over time with the introduction of generic competition. Interventions that standardize medication-naming practices may hasten this decline and increase use of nonproprietary terminology in medicine.
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