Despite strong evidence and Class I recommendations to support the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), use of these medications remain suboptimal. There is a great need to understand 1) what barriers to implementation of these therapies exist and 2) effective ways to support implementation of these therapies.

Using the Consolidated Framework for Implementation Research framework, we conducted a broad array of interviews with stakeholders in the care of patients with HFrEF across 26 health systems to determine the barriers to GDMT implementation that health systems face, and to identify any factors that facilitated GDMT implementation and titration. We conducted interviews across a variety of health system phenotypes, including academic, private, fee-for-service, and bundled payment health systems to understand whether barriers and facilitators to GDMT implementation existed across system types.

Barriers to GDMT implementation appeared to be consistent across phenotypes and included a lack of time, difficulty in maintaining GDMT across the inpatient to outpatient transition and, among non-HF specialists, a lack of knowledge of guidelines. However, differences emerged when stakeholders described whether tools (facilitators) were available to overcome these barriers to help facilitate GDMT implementation, particularly when comparing institutions with fee-for-service vs bundled payment models. Health systems using bundled payment models were more likely than fee-for-service systems to report that they had support staff such as care managers and pharmacist technicians to improve GDMT use, institutional support for improving GDMT implementation, and champions for GDMT. In contrast, systems using a fee-for-service model rarely reported that these tools were available.

In this analysis of stakeholder-reported barriers and facilitators to GDMT implementation and titration, we find health systems face similar barriers to GDMT implementation. However, we note that systems using bundled payment models are more likely to report the availability of tools to help overcome these barriers. Future work is needed to understand whether similar facilitators would be effective in fee-for-service systems, or whether alternative facilitators might be more appropriate.