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

Steinman, Michael A. MD*,†; Dimaano, Liezel BS; Peterson, Carolyn A. MA*,†,‡; Heidenreich, Paul A. MD§; Knight, Sara J. PhD∥,¶; Fung, Kathy Z. MS*,†; Kaboli, Peter J. MD, MS#,**

doi: 10.1097/MLR.0b013e3182a3e525
Original Articles

Background: Little is known about how often contextual factors such as patient preferences and competing priorities impact prescribing of guideline-recommended medications, or about the extent to which these factors are documented in medical records and available to performance measurement systems.

Methods: Mixed-methods study of 295 veterans aged 50 years and older in 4 VA health care systems who had systolic heart failure and were not prescribed a β-blocker and/or an angiotensin converting enzyme inhibitor or angiotensin-receptor blocker. Reasons for nontreatment were identified from clinic notes and from interviews with 62 primary care clinicians caring for these patients. These reasons were classified using a published taxonomy.

Results: Among 295 patients not receiving guideline-recommended drugs for heart failure, chart review identified biomedical reasons for nonprescribing in 42%–58% of patients and contextual reasons in 11%–17%. Clinician interviews identified twice as many reasons for nonprescribing as chart review (mean 1.6 vs. 0.8 reasons per patient, P<0.001). In these interviews, biomedical reasons for nonprescribing were cited in 50%–70% of patients, and contextual reasons in 64%–70%. The most common contextual reasons were comanagement with other clinicians (32%–35% of patients), patient preferences and nonadherence (15%–24%), and clinician belief that the medication is not indicated in the patient (12%–20%).

Conclusions: Contextual reasons for not prescribing angiotensin converting enzyme inhibitor / angiotensin-receptor blockers and β-blockers are present in two thirds of patients with heart failure who did not receive these medications, yet are poorly documented in medical records. The structure of medical records should be improved to facilitate documentation of contextual reasons for not providing guideline-recommended care.

Supplemental Digital Content is available in the text.

*Health Services Research and Development Research Enhancement Award Program, San Francisco VA Medical Center

Division of Geriatrics, University of California, San Francisco, CA

Department of Psychology, University of Oregon, Eugene, OR

§Department of Medicine, Palo Alto VA Health Care System, Stanford University, Stanford, CA

Veterans Affairs Office of Research and Development

Departments of Psychiatry and Urology, University of California, San Francisco, CA

#Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare System

**Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (IIR 06-080-02 and CHF QUERI-04-326), and by the National Institute on Aging and the American Federation for Aging Research (1K23-AG030999). The funders had no role in study design, data collection, analysis, interpretation, or the decision to publish this manuscript.

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Prior presentation: American Geriatrics Society Annual Meeting, Seattle, May 2012.

The authors declare no conflict of interest.

Reprints: Michael A. Steinman, MD, Health Services Research and Development Research Enhancement Award Program, San Francisco VA Medical Center, P.O. Box 181G, 4150 Clement St, San Francisco, CA 94121. E-mail:

© 2013 by Lippincott Williams & Wilkins.