University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA.
JACC Heart Fail. 2023 Nov;11(11):1579-1591. doi: 10.1016/j.jchf.2023.06.022. Epub 2023 Aug 16.
The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear.
This study examined reasons for GDMT nonintensification and characterized clinical inertia.
In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase.
Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification.
In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.
临床惰性对射血分数降低的心力衰竭（HFrEF）患者接受不优指南指导的药物治疗（GDMT）的影响仍不清楚。
本研究探讨了 GDMT 不强化的原因，并对临床惰性进行了特征描述。
在 EPIC-HF（通过电子方式传递，用于强化射血分数降低的慢性心力衰竭患者药物治疗的患者激活工具）的二次分析中，这是一项评估患者激活工具对 GDMT 使用影响的随机临床试验，我们进行了顺序、解释性混合方法研究。使用扩展的已发表分类法，根据结构化图表回顾分配了 4 类药物的非强化原因。对临床就诊的音频转录进行了分析，以进一步描述非强化原因。整合发生在解释阶段。
在完成心脏病学就诊的 292 例 HFrEF 患者中，有 185 例（63.4%）未接受治疗强化，其中 90 例（48.6%）至少有 1 次机会强化某种药物类别，但没有记录到禁忌症或障碍（即临床惰性）。非强化原因因药物类别而异，包括不良反应风险增加（范围 18.2%-31.6%）、患者不遵医嘱（范围 0.8%-1.1%）、患者偏好和信念（范围 0.6%-0.9%）、与其他提供者共同管理（范围 4.6%-5.6%）、优先考虑其他问题（范围 15.6%-31.8%）、多类（范围 16.5%-22.7%）和临床惰性（范围 22.7%-31.6%）。对 32 个临床音频记录的定性分析表明了临床惰性的共同特征：1）临床医生在没有教育或强化讨论的情况下审查药物治疗方案；2）患者稳定作为非强化的理由；3）非强化的就诊时间短于强化。
在这项全面探索 HFrEF 处方的研究中，临床惰性是更新的 GDMT 处方不优分类中药物治疗非强化的主要原因。这种方法有助于确定克服 GDMT 使用不足的策略。
