A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure

Abstract

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.

Barriers to Adoption of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure: A Mixed‐Methods Study

“…Similar to findings from a study of barriers to beta‐blocker and ACE inhibitor use in HF patients, noncardiology providers reported concerns about their respective “roles and responsibilities” (comanagement) and would defer to cardiology to initiate MRA therapy for patients who were comanaged. This reflected the sentiment that MRA therapy was a cardiology‐specific therapy outside of the norm of primary care.…”

Reasons for Not Prescribing Guideline-recommended Medications to Adults With Heart Failure

“…1, 3, 5-6, 21-23 However, it has been difficult to determine to what extent these contextual factors are truly uncommon or are simply undocumented. 19, 24-25 Our findings from clinician interviews that contextual factors were responsible for as much non-prescribing as biomedical factors suggests that performance measurement systems, most of which focus on biomedical exceptions, address only half of the issue of non-prescribing of guideline-recommended medications. This fosters a misalignment of physician incentives to provide context-sensitive care.…”

“…Reasons for not prescribing an ACE-I/ARB and/or a beta blocker were assessed based on a published taxonomy. 19 This taxonomy includes “biomedical reasons” for not receiving guideline-recommended medications for heart failure (e.g., clinical contraindications to drug therapy) and “contextual reasons,” which include the patient's life circumstances and goals as well as challenges in health care delivery (e.g., patient attitudes, competing priorities, lack of coordinated care). To be coded as a reason for non-prescribing, we required an explicit or strongly implicit statement that linked the decision not to prescribe to a specific reason for that decision (see Appendix, supplemental digital content 1 for more details).…”

Potential Overtreatment and Undertreatment of Diabetes in Different Patient Age Groups in Primary Care After the Introduction of Performance Measures

“…A study about the prescription of b-blockers in patients with coronary artery disease found a similar result (35). Several patient-related reasons for potential undertreatment have been proposed (36,37), some of which are likely to differ among age groups. Aged patients have, for instance, more often comorbidities (31) and an increased risk of adverse drug events that may restrict the therapeutic options, and their treatment preferences and needs may also differ from younger patients (38).…”