Evaluating the implementation of guideline-directed medical therapy in the treatment of chronic heart failure at public hospitals in Ethiopia

Abstract

Background: Guideline-directed medical therapy (GDMT) prolongs survival in patients with heart failure with reduced ejection fraction (HFrEF). However, different countries implement GDMT differently, and many patients are still undertreated. Therefore, this study aimed to assess GDMT utilization in patients with chronic HFrEF at the adult cardiac clinics of three selected hospitals in Addis Ababa, Ethiopia. Methods: An explanatory sequential mixed-methods (quantitative cross-sectional followed by qualitative phenomenological) study design was used to assess GDMT usage in patients with HFrEF at the study settings from September 25 to November 25, 2022. Simple random and purposive sampling techniques were used to select participants for the quantitative and qualitative studies, respectively. Adherence level was defined as good (adherence score = 1), moderate (0.5 < score <1), and poor (score ⩽0.5). Quantitative data were analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0. Logistic regression model was used to determine the association. Statistical significance was declared at p < 0.05. Qualitative data were analyzed with MAXQDA 2020. Results: Three hundred forty-one patients were included in the quantitative study. Adherence to GDMT was good in 128 (37.5%) of the patients. Patient parameters, including female gender (adjusted odds ratio (AOR) = 0.55, 95% CI: 0.32–0.93), unable to read and write (AOR = 0.31, 95% CI: 0.11–0.86), primary education (AOR = 0.27, 95% CI: 0.12–0.63), were negatively associated with Physicians’ good adherence. Hypertension was associated with lower odds of physicians’ good adherence (AOR = 0.41, 95% CI: 0.21–0.78). Absence of comorbidities (other than hypertension; AOR = 2.65, 95% CI: 1.36–5.15) were positive predictors. System, patient, and physician-related factors were reported as barriers to intensifying GDMT. Conclusion: Nearly one-fourth of eligible patients were on ⩽50% of guidelines-recommended drugs. Female gender, educational level, and comorbidities were the factors associated with adherence to GDMT. System, patient, and physician-related reasons for poor adherence were identified. Multipronged interventions are required to address those adherence barriers.