Barriers and facilitators to the uptake of the Ischaemia with Non-Obstructive Coronary Arteries (INOCA) recommendation by cardiologists in the Netherlands: A qualitative study

Background: Ischemia with No Obstructive Arteries (INOCA) is a condition characterized by an elusive diagnosis and a significant impact on patients' quality of life. Recent evidence challenges previous assumptions about INOCA's benign prognosis, emphasizing the increased downstream risks associated with condition. A 2020 Dutch Society for Cardiology (NVVC) recommendation aims to guide cardiologists in the management of INOCA, but its adoption in practice varies. This study explores the interconnecting factors influencing the uptake of the INOCA recommendation. Methods: A qualitative interview study was performed to investigate cardiologists' adoption of the 2020 NVVC INOCA recommendation in the Netherlands, utilizing the Theoretical Domains Framework and COM-B model. A diverse sample of Dutch cardiologists was recruited and digital semi-structured interviews were conducted and analyzed using directed content analysis. Results: A total of 14 Dutch cardiologists (6 women, 8 men) was interviewed to explore factors influencing their uptake of the 2020 NVVC INOCA recommendation. The immediate influences on uptake were grouped into three domains: capabilities, opportunities, and motivation according to the COM-B model. Most importantly, underlying assumptions about the evidence base, diagnostic accuracy, and gendered stereotypes significantly influenced recommendation uptake. Conclusions: Underlying assumptions about the disease entity and the affected patient, which are seldom investigated in implementation research, significantly affect the overall uptake of the INOCA guideline. Careful investigation of these assumptions is necessary to challenge them and foster an environment conducive to the uptake of structural implementation measures.