MAGNITUDE AND FACTORS INFLUENCINGOPTIMALESCALATION OF GUIDELINE-DIRECTED MEDICALTHERAPYAMONG CHRONIC HEART FAILURE PATIENTS WITHREDUCEDEJECTION FRACTION IN COMPREHENSIVE HOSPITALSOFCENTRAL ETHIOPIAN REGION, ETHIOPIA. A CROSS SECTIONALSTUDY.

Abstract

and dose optimization of GDMT remain sub-optimal inmanylowresource settings. This study assessed the magnitude and factors influencing optimal escalationof GDMT among HFrEF patients in comprehensive hospitals of Central Ethiopia. Methods: A mixed-methods, institution-based cross-sectional study was conductedamongadultHFrEF patients attending medical referral clinics in selected comprehensive hospitals in Central Ethiopia. Quantitative data were collected from 93 patients using structured tools andanalyzedwith SPSS version 23. multivariable logistic regression was used to identify factors associatedwith GDMT optimization. In parallel, key informant interviews were conducted withcliniciansand pharmacists, and facility observations were performed to explore system-level barriers. Thematic analysis was used for qualitative data. Results: Although most patients received at least one component of GDMT, noneachieve doptimal beta-blocker dosing, and 63% were taking less than 25%of the recommended target dose. Use of sodium-glucose co-transporter 2 inhibitors (SGLT2is) was verylimited. On multivariable analysis, higher systolic blood pressure (AOR = 1.047, 95%CI: 1.003–1.093), the absence of community-based health insurance (CBHI) (AOR = 0.288, 95%CI: 0.091–0.915),and longer duration of heart failure (AOR = 1.572, 95% CI: 1.055–2.344) were independently associated with mineralocorticoid receptor antagonists (MRAs) use. No significant predictors were identified for angiotensin converting enzyme inhibitor (ACEI), and SGLT2I escalation. Qualitative findings revealed limited availability of GDMT medications, lack of training onheart failure management, absence of local guidelines and protocols, high patient load, and supply chain and insurance-related constraints as major barriers to optimization. Conclusion: Optimal escalation of GDMT among HFrEF patients in Central Ethiopiai markedly sub-optimal, particularly for beta-blockers and newer therapies. System-level and provider-level barriers, rather than patient factors, predominantly limit implementation. Strengthening drug supply systems, clinical guidelines, provider training, and alongside improving the effectiveness of CBHI, is essential to translate evidence-based recommendations into improved patient outcomes.