J Am Pharm Assoc (2003). 2024 Nov-Dec;64(6):102224. doi: 10.1016/j.japh.2024.102224. Epub 2024 Aug 28.
Despite sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor/neprilysin inhibitors (ARNi) being cost-effective evidenced-based therapies for the management of Heart Failure with Reduced Ejection Fraction (HFrEF), research shows that less than 30% of patients with HFrEF are prescribed these agents.
This study aimed to understand clinician-perceived barriers and facilitators to prescribing ARNi and SGLT2i in patients with HFrEF.
We conducted virtual and in-person semi-structured interviews in a large integrated healthcare delivery system in the United States. Twenty cardiology clinicians managing patients with HFrEF were recruited using purposeful sampling to target providers across professions and practice sites. The interview guide was developed based on a literature review and insights from a practicing cardiologist. It inquired about perceived prescribing behaviors, focusing on factors affecting the use of ARNi and SGLT2i. We identified key themes using rapid qualitative analysis.
Twenty clinicians were interviewed: 13 physicians, 5 advanced practitioners, and 2 clinic-based pharmacists. Eighteen interviews were analyzed; we excluded 2 as the clinicians interviewed did not meet the inclusion criteria. Three major themes were identified: 1) clinician-reported prescribing patterns don't always align with the American College of Cardiology/American Heart Association guidelines for the use of SGLT2i and ARNi due to clinical inertia, lack of familiarity, knowledge, and comfort with use, and concerns over polypharmacy or adverse events, 2) clinician-perceived and actual out-of-pocket cost reduced prescribing of ARNi or SGLT2i to patients, exacerbated by a lack of visibility into patients' prescription coverage, denials of coverage by insurance, and navigating prior authorization related workflows, and 3) incorporation of a clinic-based pharmacist increased the prescribing of these medications.
Increasing cost transparency, implementing interventions to overcome clinical inertia and cost hurdles, and increasing clinic-based pharmacist support may improve evidenced-based prescribing in patients with HFrEF, especially for comparatively novel classes such as ARNi and SGLT2i.
尽管钠-葡萄糖共转运蛋白 2 抑制剂（SGLT2i）和血管紧张素受体/脑啡肽酶抑制剂（ARNi）是具有成本效益的心力衰竭伴射血分数降低（HFrEF）管理的循证治疗方法，但研究表明，只有不到 30%的 HFrEF 患者开具了这些药物。
本研究旨在了解临床医生在开具 HFrEF 患者 ARNi 和 SGLT2i 时的认知障碍和促进因素。
我们在美国一家大型综合医疗服务系统中进行了虚拟和现场半结构式访谈。通过有目的的抽样，招募了 20 名管理 HFrEF 患者的心脏病学临床医生，以针对不同专业和实践地点的提供者。访谈指南是基于文献回顾和一位执业心脏病专家的见解制定的。它询问了认知处方行为，重点关注影响 ARNi 和 SGLT2i 使用的因素。我们使用快速定性分析确定了关键主题。
对 20 名临床医生进行了访谈：13 名医生，5 名高级执业医师，2 名诊所药剂师。分析了 18 次访谈；我们排除了 2 次，因为接受访谈的临床医生不符合纳入标准。确定了三个主要主题：1）由于临床惯性、缺乏熟悉度、使用知识和舒适度以及对多药治疗或不良反应的担忧，临床医生报告的处方模式并不总是与美国心脏病学会/美国心脏协会关于 SGLT2i 和 ARNi 使用的指南一致；2）临床医生感知和实际的自付费用降低了患者的 ARNi 或 SGLT2i 处方，这加剧了对患者处方覆盖范围、保险拒付和导航预先授权相关工作流程的缺乏可见性；3）诊所药师的参与增加了这些药物的处方。
提高成本透明度、实施克服临床惯性和成本障碍的干预措施以及增加诊所药师支持可能会改善 HFrEF 患者的循证处方，特别是对于 ARNi 和 SGLT2i 等相对较新的类别。
