Assessment of prescriber adherence to guideline-directed medical therapy for heart failure at Jimma Medical Center, Ethiopia

Abstract

Background: Heart failure with reduced ejection fraction (HFrEF) requires guideline-directed medical therapy (GDMT) to reduce morbidity and mortality. However, adherence to GDMT is often suboptimal in resource-limited settings, such as the Jimma Medical Center, Ethiopia. Objectives: To assess prescriber adherence to guideline-based medical therapy in heart failure at Jimma Medical Center, Ethiopia. Methods: A convergent mixed-methods study was conducted from December 2023 to April 2024, enrolling 215 adult HFrEF patients. Prescriber adherence was measured using the Guideline Adherence Index (GAI) and QUALIFY scores. Semi-structured interviews with physicians explored the qualitative factors that affect adherence. Multinomial logistic regression identified the factors associated with adherence. Results: Only 13.5 % of patients were discharged on all four recommended GDMT classes (ACEI/ARB, beta-blockers, MRAs, and SGLT2 inhibitors). Moderate and poor prescriber adherence occurred in 70.1 % and 16.3 % of the cases, respectively. Patient adherence was higher (74.9 % by MARS-5), yet 94 % were physically inactive, and 54.4 % regularly consumed salt. Insurance coverage (AOR: 4.81; p = 0.001), salt restriction (AOR: 6.62; p = 0.003), and shorter hospital stays (AOR: 0.90; p = 0.005) were linked to better adherence, whereas higher ejection fraction (AOR: 1.07; p = 0.005) and more comorbidities (AOR: 2.36; p = 0.037) predicted poorer adherence. The qualitative findings highlighted medication stock-outs, financial barriers, and clinical complexities as key challenges, with institutional support and multidisciplinary care as facilitators. Conclusions: Prescriber and patient adherence to GDMT for HFrEF at Jimma Medical Center was suboptimal. Interventions targeting prescriber training, expansion of insurance coverage, patient education, and multidisciplinary care are needed to improve outcomes.