TY - JOUR
AU - S. E. Philbin
AU - L. P. Gleason
AU - S. D. Persell
AU - E. Walter
AU - L. C. Petito
AU - A. Tibrewala
AU - C. W. Yancy
AU - R. S. Beidas
AU - J. E. Wilcox
AU - R. K. Mutharasan
AU - D. Lloyd-Jones
AU - M. J. O'Brien
AU - A. N. Kho
AU - M. C. McHugh
AU - J. D. Smith
AU - F. S. Ahmad
A1 - 
AB - BACKGROUND: Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators) of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. METHODS: We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or federally qualified health centers (FQHCs). We report results with a conceptual model integrating two frameworks: (1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of others' attitudes, and perceived behavioral control influence intentions and behaviors; and (2) the Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. RESULTS: Thirty-one clinicians, including 18 (58%) primary care and 13 (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. CONCLUSIONS: Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.
AD - Center for Education in Health Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; AllianceChicago, Chicago, IL, USA.; Icahn School of Medicine at Mount Sinai, New York, NY, USA.; Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.; Division of Health System Innovation and Research, Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA.; Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. faraz.ahmad@northwestern.edu.; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. faraz.ahmad@northwestern.edu.; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. faraz.ahmad@northwestern.edu.
AN - 40325339
BT - J Gen Intern Med
C5 - Education & Workforce; Healthcare Disparities
DA - May 5
DO - 10.1007/s11606-025-09515-5
DP - NLM
ET - 20250505
JF - J Gen Intern Med
LA - eng
N2 - BACKGROUND: Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators) of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. METHODS: We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or federally qualified health centers (FQHCs). We report results with a conceptual model integrating two frameworks: (1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of others' attitudes, and perceived behavioral control influence intentions and behaviors; and (2) the Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. RESULTS: Thirty-one clinicians, including 18 (58%) primary care and 13 (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. CONCLUSIONS: Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.
PY - 2025
SN - 0884-8734
ST - Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally Qualified Health Centers: A Thematic Qualitative Analysis
T1 - Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally Qualified Health Centers: A Thematic Qualitative Analysis
T2 - J Gen Intern Med
TI - Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally Qualified Health Centers: A Thematic Qualitative Analysis
U1 - Education & Workforce; Healthcare Disparities
U3 - 10.1007/s11606-025-09515-5
VO - 0884-8734
Y1 - 2025
ER -