Barriers and Enablers to Guideline-Directed Prescribing for Heart Failure with Reduced Ejection Fraction: A Multi-Stakeholder Qualitative Study.

Semi-structured interviews with 38 healthcare providers across seven public institutions in Singapore were used to explore barriers and enablers to guideline-directed prescribing for HFrEF.

• Participants included cardiologists, clinicians from relevant subspecialties, nurses, and pharmacists.
• The study was informed by the Cabana framework.
• Data were analysed using an inductive-deductive approach.
• The setting was a multi-ethnic Asian healthcare context.

Guideline awareness was generally high among providers, but confidence in initiating and up-titrating quadruple therapy varied.

• The abstract states that "Guideline awareness was generally high, but confidence in initiating and up-titrating therapy varied."
• This points to a gap between knowing the guidelines and applying them in practice.

Attitudinal barriers included a perceived gap between clinical trial evidence and the realities of managing diverse patient populations, safety concerns in multi-morbid patients, clinical inertia, professional boundary challenges, and limited confidence among junior staff.

• The perceived evidence gap was particularly relevant for older and multimorbid patients.
• Interprofessional relationships and professional boundaries influenced prescribing.
• Limited confidence among junior staff was identified as a barrier.

Guidelines were perceived as enablers because they provide a shared framework that promotes standardised care.

• This enabling role coexisted with the attitudinal barriers toward applying guidelines to diverse real-world patients.

Patient-related factors shaped prescribing behaviour, including financial constraints, limited health literacy, cultural preferences for traditional medicines, and treatment outcomes.

• Positive patient outcomes were identified as an enabler of adherence to guideline recommendations.
• The authors call for increased financial support for patients and strengthened adherence through dedicated heart failure nurses or case managers.

Organisational barriers included limited access to specialist follow-up, rotating inpatient teams, formulary gaps in primary care, and fragmented medical records.

• Fragmented health records and formulary gaps in primary care were described as hindering implementation.
• The authors recommend increased government support for healthcare information integration.

Multidisciplinary nurse- or pharmacist-led titration clinics with specialist support were a key institutional enabler.

• The study included nurses and pharmacists as well as doctors, covering all three frontline professional groups.
• Authors suggest clearer task-sharing pathways and primary care-based medication titration may enhance implementation.

The authors propose that targeted toolkits, specialist support, review of quadruple therapy at discharge and follow-up, real-time prescribing monitoring, and telehealth or primary care-based services are needed to narrow the guideline-practice gap.

• Toolkits and specialist support are intended to address concerns and build staff confidence.
• A culture of reviewing quadruple therapy prescription at discharge and during follow-up should be supported.
• Prescribing patterns should be monitored and reflected in real time.
• Improved decision tools and better health information integration were also suggested.

This study is described as one of the first multi-institutional qualitative accounts of barriers and enablers to GDMT prescribing for HFrEF in Singapore to include doctors, nurses, and pharmacists.

• Prior implementation-barrier studies focused mainly on physicians.
• The study identifies individual, organisational, and system-level factors.