title: Reasons for not prescribing guideline-recommended medications to adults with heart failure.
abstract: 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.
authors: *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.
authors: Michael A
authors: MA
authors: Steinman
authors: Liezel
authors: L
authors: Dimaano
authors: Carolyn A
authors: CA
authors: Peterson
authors: Paul A
authors: PA
authors: Heidenreich
authors: Sara J
authors: SJ
authors: Knight
authors: Kathy Z
authors: KZ
authors: Fung
authors: Peter J
authors: PJ
authors: Kaboli
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D005260:Female; D019983:Guideline Adherence; D054143:Heart Failure, Systolic / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D057240:Patient Preference / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D055553:Prescription Drugs / Q000627:therapeutic use*; D012189:Retrospective Studies; D014728:Veterans / Q000523:psychology / Q000706:statistics & numerical data; D016903:Drug Monitoring
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D055553:Prescription Drugs
references: Circulation. 2008 Jun 3;117(22):2884-92
references: 18506011
references: N Engl J Med. 2006 Jul 27;355(4):375-84
references: 16870916
references: N Engl J Med. 2003 May 29;348(22):2218-27
references: 12773650
references: Ann Intern Med. 2011 May 3;154(9):627-34
references: 21536939
references: J Gen Intern Med. 2011 Oct;26(10):1152-9
references: 21604076
references: Public Health Rep. 2007 Jan-Feb;122(1):93-100
references: 17236614
references: Arch Intern Med. 2006 Nov 13;166(20):2272-7
references: 17101947
references: N Engl J Med. 2008 Jul 17;359(3):274-84
references: 18635432
references: JAMA. 2005 Aug 10;294(6):741-3
references: 16091578
references: N Engl J Med. 2012 Apr 26;366(17):1606-15
references: 22455751
references: Am J Geriatr Pharmacother. 2010 Dec;8(6):583-94
references: 21356507
references: BMJ. 2003 Jan 25;326(7382):196
references: 12543836
references: Am J Manag Care. 2001 Nov;7(11):1033-43
references: 11725807
references: JAMA. 2007 Sep 12;298(10):1209-12
references: 17848656
references: Ann Fam Med. 2009 Mar-Apr;7(2):121-7
references: 19273866
references: Med Care. 2003 Oct;41(10):1173-82
references: 14515113
references: Am J Geriatr Pharmacother. 2012 Jun;10(3):211-8
references: 22579695
references: Med J Aust. 2004 Jul 19;181(2):78-81
references: 15257642
references: BMJ. 2012 Apr 17;344:e2405
references: 22511209
references: Arch Intern Med. 2010 Mar 22;170(6):566-9
references: 20308644
references: Ann Intern Med. 2010 Feb 16;152(4):225-31
references: 20157137
references: Ann Intern Med. 2011 Feb 15;154(4):227-34
references: 21320938
references: Ann Intern Med. 2007 Feb 20;146(4):270-7
references: 17310051
references: Am J Cardiol. 2004 Mar 15;93(6):714-8
references: 15019875
references: Ann Intern Med. 2010 Jul 20;153(2):69-75
references: 20643988
references: Drugs Aging. 2008;25(2):131-44
references: 18257600
references: Am J Cardiol. 1997 Apr 15;79(8):1118-20
references: 9114778
references: Ann Intern Med. 2012 Dec 4;157(11):785-95
references: 22964778
references: Arch Intern Med. 2012 Jun 25;172(12):938-45
references: 22641246