Emily B Levitan1, Melissa K Van Dyke2, Matthew Shane Loop3, Ronan O'Beirne4, Monika M Safford5. 1. Department of Epidemiology, University of Alabama at Birmingham, RPHB 220, Birmingham, AL, 35294-0022, USA. elevitan@uab.edu. 2. Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA. 3. Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA. 4. Division of Continuing Medical Education, University of Alabama at Birmingham, Birmingham, AL, USA. 5. General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.
Abstract
PURPOSE: For patients with heart failure with reduced ejection fraction (HFrEF), guidelines recommend use of beta-blockers with gradual up-titration. However, many patients with HFrEF do not use beta-blockers and up-titration is rare. Our purpose was to identify and rank barriers to beta-blocker use and up-titration from the perspective of primary care physicians. METHODS: We conducted 4 moderated, structured group discussions among 19 primary care physicians using the nominal group technique; 16 participants also completed a survey. Participants generated lists of barriers to beta-blocker use and up-titration among patients with HFrEF. Each participant had six votes with three votes assigned to the item ranked most important, two to the second most important item, and one to the third most important item. Investigators characterized items into themes. The percentage of available votes was calculated for each theme. RESULTS: Fifteen of 16 participating primary care physicians who completed the survey reported that management of beta-blockers was their responsibility. Treatment/side effects, particularly hypotension, were identified as the most important barrier for beta-blocker use (72% of available votes) followed by polypharmacy (11%), healthcare system barriers (10%), and comorbidities (6%). Barriers to up-titration included treatment/side effects (49% of available votes), patient communication/buy-in (21%), polypharmacy (13%), and healthcare system barriers (8%). CONCLUSIONS: Many barriers to guideline concordant use of beta-blockers among patients with HFrEF identified by primary care providers are not readily modifiable. Addressing these barriers may require development, testing, and dissemination of protocols for beta-blocker initiation and up-titration that are safe and appropriate in primary care.
PURPOSE: For patients with heart failure with reduced ejection fraction (HFrEF), guidelines recommend use of beta-blockers with gradual up-titration. However, many patients with HFrEF do not use beta-blockers and up-titration is rare. Our purpose was to identify and rank barriers to beta-blocker use and up-titration from the perspective of primary care physicians. METHODS: We conducted 4 moderated, structured group discussions among 19 primary care physicians using the nominal group technique; 16 participants also completed a survey. Participants generated lists of barriers to beta-blocker use and up-titration among patients with HFrEF. Each participant had six votes with three votes assigned to the item ranked most important, two to the second most important item, and one to the third most important item. Investigators characterized items into themes. The percentage of available votes was calculated for each theme. RESULTS: Fifteen of 16 participating primary care physicians who completed the survey reported that management of beta-blockers was their responsibility. Treatment/side effects, particularly hypotension, were identified as the most important barrier for beta-blocker use (72% of available votes) followed by polypharmacy (11%), healthcare system barriers (10%), and comorbidities (6%). Barriers to up-titration included treatment/side effects (49% of available votes), patient communication/buy-in (21%), polypharmacy (13%), and healthcare system barriers (8%). CONCLUSIONS: Many barriers to guideline concordant use of beta-blockers among patients with HFrEF identified by primary care providers are not readily modifiable. Addressing these barriers may require development, testing, and dissemination of protocols for beta-blocker initiation and up-titration that are safe and appropriate in primary care.
Entities:
Keywords:
Beta-blockers; Clinical practice; Heart failure; Qualitative research methods
Authors: Matthew Shane Loop; Melissa K van Dyke; Ligong Chen; Monika M Safford; Meredith L Kilgore; Todd M Brown; Raegan W Durant; Emily B Levitan Journal: J Card Fail Date: 2018-10-16 Impact factor: 5.712
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Authors: Ozan Unlu; Emily B Levitan; Evgeniya Reshetnyak; Jerard Kneifati-Hayek; Ivan Diaz; Alexi Archambault; Ligong Chen; Joseph T Hanlon; Mathew S Maurer; Monika M Safford; Mark S Lachs; Parag Goyal Journal: Circ Heart Fail Date: 2020-10-13 Impact factor: 8.790