Reasons for not prescribing guideline-recommended medications to adults with heart failure

Med Care. 2013 Oct;51(10):901-7. doi: 10.1097/MLR.0b013e3182a3e525.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Aged
  • Aged, 80 and over
  • Angiotensin Receptor Antagonists / therapeutic use*
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Female
  • Guideline Adherence*
  • Heart Failure, Systolic / drug therapy*
  • Humans
  • Male
  • Medication Adherence / statistics & numerical data
  • Middle Aged
  • Patient Preference / statistics & numerical data
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Prescription Drugs / therapeutic use*
  • Retrospective Studies
  • Veterans / psychology
  • Veterans / statistics & numerical data


  • Adrenergic beta-Antagonists
  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Prescription Drugs