{ "abstract": "Background:: Heart failure with reduced ejection fraction remains a major cause of morbidity and mortality despite effective treatments. Guideline-directed medical therapy, commonly referred to as quadruple therapy, reduces mortality and hospitalisation; however, uptake and dose optimisation remain suboptimal across Asia, including Singapore. This study explores barriers and enablers influencing prescribing and titration practices in a multi-ethnic Asian setting.\n\nMethods:: We conducted semi-structured interviews with 38 healthcare providers from seven public healthcare institutions in Singapore, including cardiologists, clinicians from relevant subspecialties, nurses, and pharmacists. The study was informed by the Cabana framework, and data were analysed using an inductive-deductive approach.\n\nResults:: Guideline awareness was generally high, but confidence in initiating and up-titrating therapy varied. Attitudinal barriers included perceived gaps between clinical trial evidence and the realities of managing diverse patient populations, safety concerns in multi-morbid patients, clinical inertia, challenges related to professional boundaries, and limited confidence among junior staff. Nonetheless, guidelines were perceived as enablers, providing a shared framework that promotes standardised care. Prescribing behaviour was shaped by patient-related factors including financial constraints, limited health literacy, cultural preferences for traditional medicines, and treatment outcomes. Organisational barriers included limited access to specialist follow-up, rotating inpatient teams, formulary gaps in primary care, and fragmented medical records. Multidisciplinary nurse- or pharmacist-led titration clinics with specialist support were a key institutional enabler.\n\nConclusions:: To narrow the guideline-practice gap, targeted toolkits and specialist support are needed 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, and patient adherence strengthened through dedicated heart failure nurses or case managers. Telehealth or primary care-based services, increased government support for healthcare information integration, and increased financial support for patients are necessary.\n\nLay Summary: Heart failure with reduced ejection fraction is a serious medical condition that can lead to frequent hospital admissions and premature death. Clinical guidelines strongly recommend the use of four classes of evidence-based medicines, commonly known as quadruple therapy, because they can significantly improve survival and reduce hospitalisation. Despite guideline endorsement, real-world uptake and dose optimisation of quadruple therapy remains suboptimal globally.\n\nStudies on implementation barriers in adhering to the guideline recommendations for quadruple therapy have focused mainly on physicians. This study provides one of the first multi-institutional qualitative accounts of barriers and enablers in prescribing quadruple therapy or guideline-directed medical therapy (GDMT) for heart failure patients in Singapore, exploring the views of all three frontline healthcare professional groups—doctors, nurses, and pharmacists.\n\nWe found that the prescription of quadruple therapy was negatively influenced by a perceived gap between clinical trial evidence and the realities of managing diverse patient populations—particularly older and multimorbid patients—alongside interprofessional relationships and limited confidence among junior staff. Health care providers’ prescribing behaviour was shaped by patient-related factors, including financial constraints, limited health literacy, and cultural preferences for traditional medicines.\n\nLimited specialist follow-up, fragmented health records, and formulary gaps in primary care hinder implementation, while positive patient outcomes and multidisciplinary care models act as enablers in adhering to guideline recommendations.\n\nThe study adds context-specific implementation insights by identifying individual, organisational, and system-level factors. Specialist-supported nurse- or pharmacist-led services, primary care-based medication titration, clearer task-sharing pathways, improved decision tools, and better health information integration may enhance guideline implementation.", "abstract_shown": true, "affiliations": [ "Health Services Research and Population Health, Duke-NUS Medical School, 8 College Road, Singapore", "Department of Cardiology, National Heart Centre, 5 Hospital Drive, Singapore", "National Heart Research Institute Singapore, National Heart Centre, 5 Hospital Drive, Singapore", "Australian Centre for Health Services Innovation, School of Public Health and Social Work, QUT Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, 88 Musk Avenue, Kelvin Grove, QLD 4059, Australia", "Yong Loo Lin School of Medicine, National University Singapore, 10 Medical Dr, Singapore", "Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Rd, Singapore", "Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore", "Internal Medicine, Singapore General Hospital, Outram Road, Singapore", "Changi General Hospital, 2 Simei Street 3, Singapore", "Department of Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore", "Khoo Teck Puat Hospital, 90 Yishun Central, Singapore", "Cardiovascular & Metabolic Disorders Program, Duke-NUS Medical School, 8 College Road, Singapore", "The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, United Kingdom", "Cardiovascular Disease National Collaborative Enterprise, 23 Rochester Park, #06-01, Singapore", "Duke-NUS Medical School, 8 College Road, Singapore" ], "article_type": "research article", "arxiv": null, "author_total": 17, "authors": [ { "affs": [ 0 ], "name": "Thin Mar Win", "orcid": "0000-0002-6804-278X" }, { "affs": [ 1 ], "name": "Audry Shan Yin Lee", "orcid": "0000-0001-9164-6736" }, { "affs": [ 0, 2, 3 ], "name": "Sameera Senanayake", "orcid": "0000-0002-5606-2046" }, { "affs": [ 0 ], "name": "Nicholas Graves", "orcid": "0000-0002-5559-3267" }, { "affs": [ 0, 2 ], "name": "Sanjeewa Kularatna", "orcid": "0000-0001-5650-154X" }, { "affs": [ 4, 5 ], "name": "Raymond Ching Chiew Wong", "orcid": "0000-0001-6224-4543" }, { "affs": [ 6 ], "name": "Seet Yoong Loh" }, { "affs": [ 7 ], "name": "Tan Yuyang" }, { "affs": [ 8 ], "name": "Huang Weiliang", "orcid": "0000-0002-0702-0771" }, { "affs": [ 8 ], "name": "Chow Weien", "orcid": "0000-0003-3275-3114" }, { "affs": [ 9 ], "name": "Jeanne Shan Yin Ong" }, { "affs": [ 10 ], "name": "Peck Kah Hua" }, { "affs": [ 2, 4, 11, 12, 13 ], "name": "Derek J. Hausenloy", "orcid": "0000-0003-0729-4956" }, { "affs": [ 4, 5, 13 ], "name": "Mark Yan-Yee Chan", "orcid": "0000-0003-0389-7450" }, { "affs": [ 1, 14 ], "name": "Khung-Keong Yeo", "orcid": "0000-0002-5457-4881" }, { "affs": [ 1 ], "name": "Kheng Leng David Sim", "orcid": "0000-0002-5136-9460" }, { "affs": [ 0 ], "name": "Sungwon Yoon", "orcid": "0000-0001-9458-6097" } ], "bibtex": "https://research.draconitic.com/paper/77q6zk0d4j0ez.bib", "cited_by": 0, "doi": "10.5334/gh.1596", "fulltext_url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13722010/?tool=EBI", "id": "77q6zk0d4j0ez", "issns": [ "2211-8160", "2211-8179" ], "landing_url": "https://europepmc.org/article/PMC/PMC13722010", "language": "eng", "licence": "CC-BY", "licence_label": "CC BY", "licence_source": "article", "licence_url": "https://creativecommons.org/licenses/by/4.0/", "metadata_licence": null, "native_subjects": [ [ "heading", "Original Research" ], [ "openalex", "2705|Heart Failure Treatment and Management" ] ], "openalex": "W7224907232", "pdf_url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13722010/pdf/?tool=EBI", "pmcid": "PMC13722010", "pmid": "42965135", "published": "2026-10-30", "publisher": "Ubiquity Press", "ris": "https://research.draconitic.com/paper/77q6zk0d4j0ez.ris", "sources": [ { "first_seen": "2026-10-31T12:21:36Z", "native_id": "PMC:PMC13722010", "source": "europepmc", "url": "https://europepmc.org/article/PMC/PMC13722010" }, { "first_seen": "2026-11-03T12:22:36Z", "native_id": "PMC13722010", "source": "pmc", "url": "https://doi.org/10.5334/gh.1596" } ], "subjects": [ { "field": "medicine", "origin": "openalex:2705|Heart Failure Treatment and Management", "subfield": "cardiovascular" } ], "title": "Barriers and Enablers to Guideline-Directed Prescribing for Heart Failure with Reduced Ejection Fraction: A Multi-Stakeholder Qualitative Study", "title_text": "Barriers and Enablers to Guideline-Directed Prescribing for Heart Failure with Reduced Ejection Fraction: A Multi-Stakeholder Qualitative Study", "type": "peer-reviewed", "updated_at": "2026-11-03T12:22:36Z", "url": "https://research.draconitic.com/paper/77q6zk0d4j0ez", "venue": "Global heart", "versions": [] }