Barriers to prescribing and insurance approval of SGLT2 inhibitors for heart failure: a mixed-methods study in Jordan

Background: Sodium-glucose cotransporter 2 inhibitors are now cornerstone therapy for heart failure across the ejection fraction spectrum, independent of diabetes status. Despite strong guideline recommendations, real-world uptake remains suboptimal, especially in middle-income settings. Evidence on the interplay between prescribing decisions and insurance authorization processes is limited. Objectives: To explore knowledge, attitudes, prescribing practices, and authorization decision-making related to SGLT2 inhibitors for HF among treating physicians and insurance physicians in Jordan, and to identify system-level barriers to evidence-based use. Methods: An explanatory sequential mixed-methods design was used. A cross-sectional survey was conducted among treating physicians (general practitioners, family medicine, internal medicine) and insurance physicians involved in medication authorization. The validated questionnaire was analyzed with descriptive statistics and multivariable logistic regression. Semi-structured interviews followed with a purposive sample; reflexive thematic analysis was applied. Findings were integrated using joint displays. Results: Of 312 physicians surveyed (214 treating, 98 insurance), treating physicians showed moderate-to-good knowledge and favorable attitudes toward SGLT2 inhibitors in HF, yet initiation rates were low. Consistent insurance approval for HF without diabetes occurred in fewer than one-third of cases. Misclassification of SGLT2 inhibitors as diabetes-only medications was prevalent among insurance physicians (61.2%) and the strongest predictor of rejection (adjusted OR 0.18, 95% CI 0.10-0.33). Lack of guideline-aligned protocols and non-cardiologist prescriber status further reduced approval. Qualitative data highlighted drug-class identity, professional hierarchies, cost accountability, and defensive decision-making as key influences. Integrated findings showed system-level factors overriding physician knowledge and intent. Conclusion: Barriers to SGLT2 inhibitor use for HF in Jordan are predominantly systemic. Misclassification and misalignment between evidence and insurance frameworks hinder guideline-directed care. Policy interventions, updating reimbursement structures, standardizing criteria, and involving stakeholders, are essential to improve access.