OBJECTIVES:

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a cost-effective, Class 1A therapy for the management of Heart Failure with Reduced Ejection Fraction (HFrEF) according to the 2022 AHA/ACC/HFSA Guideline. Despite this, less than 20% of patients with HFrEF are treated with SGLT2i’s. We aimed to understand barriers and facilitators that influence prescribing of SGLT2i in patients with HFrEF.

METHODS:

We conducted virtual and in-person semi-structured interviews with cardiology clinicians caring for patients with HFrEF using purposeful sampling to target providers across degrees and practice sites at an integrated health delivery network. The interview guide was developed based on a review of the literature and insights from a practicing cardiologist, and inquired about perceived prescribing behaviors and medication preference, with a focus on factors affecting the use of SGLT2i’s. Rapid qualitative analysis was performed on completed transcripts.

RESULTS:

Twenty clinicians were interviewed: 13 physicians, 5 advanced practitioners and 2 clinical pharmacists. Eighteen interviews were analyzed; two were excluded as clinicians did not manage HFrEF patients in outpatient settings. We identified 3 major themes: 1) clinician-reported don’t always align with the 2022 guidelines for use of SGLT2i’s often due to clinical inertia, polypharmacy concerns, or lack of familiarity with use; 2) incorporation of a clinical pharmacist increased the prescribing of SGLT2i’s; and 3) cost of care (actual and perceived), that encompassed lack of visibility into patients’ prescription coverage and potential out-of-pocket expenses at the point of prescribing, denial of coverage for SGLT2i’s, and navigating the Medicare coverage gap, was a major barrier to prescribing SGLT2i’s.

CONCLUSIONS:

Clinicians highlighted several barriers, including actual and perceived costs and one facilitator to improve guideline-concordant prescribing. This information may inform efforts that seek to improve the prescribing of SGLT2is and adoption of evidenced-based treatment for patients with HFrEF.