Barriers and Enablers to Guideline-Directed Prescribing for Heart Failure with Reduced Ejection Fraction: A Multi-Stakeholder Qualitative Study

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. Methods: 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. Results: 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. Conclusions: 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. Lay 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. Studies 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. We 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. Limited 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. The 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.