Barriers To SGLT2 Inhibitor Access In Heart Failure Care In Jordan

Key Takeaways:

• Low initiation and low reported approval for heart failure without diabetes were observed despite generally favorable physician knowledge and attitudes toward SGLT2 inhibitors.
• Misclassification of SGLT2 inhibitors as diabetes-only medications was associated with rejection and was identified as the strongest quantitative predictor in the analysis.
• Specialty, internal approval rules, coding practices, and cost-related review themes were described as recurring factors in access decisions.

The study examined treatment initiation, insurance approval, and barriers affecting access in routine heart failure care. Physicians generally reported favorable views, yet use and approval remained limited. The findings describe a gap between prescribing intent and insurance approval pathways.

The analysis combined survey findings, multivariable modeling, and qualitative interviews to examine implementation barriers. Investigators reported that initiation remained low, and consistent insurance approval for heart failure without diabetes occurred in fewer than one-third of cases. Survey responses again indicated moderate-to-good physician knowledge and generally favorable attitudes toward the drug class. Overall, reported familiarity with the therapy exceeded real-world authorization for its use.

Investigators found that insurance physicians misclassified SGLT2 inhibitors as diabetes-only medications in 61.2% of respondents. In multivariable analysis, misclassification was the strongest factor associated with rejection (adjusted OR 0.18; 95% CI, 0.10–0.33), aligning with lower odds of approval when SGLT2 inhibitors were viewed as diabetes-only drugs. Qualitative findings similarly suggested that drug-class identity and related review heuristics (eg, treating SGLT2 inhibitors as diabetes-only medications) influenced authorization decisions. The study tied coverage denials most closely to how the drug class was categorized during authorization review.

Prescriptions written by cardiologists were more likely to be approved than those written by internal medicine or general and family medicine physicians. Interviews linked this pattern to a recurring sense that specialty affiliation conveyed added legitimacy during authorization review. Participants also described reliance on internal drug lists, ICD coding, prior authorization steps, and role-based approval logic when requests were assessed. These accounts suggest that approval decisions reflected institutional workflow as much as the prescription itself.

Interview findings also described limited standardized heart failure protocols, cost accountability, and defensive decision-making as recurring influences on reimbursement decisions. The authors interpreted the integrated findings as showing that physician knowledge and positive attitudes were not enough to overcome structural authorization barriers in the Jordanian system. Across quantitative and qualitative results, access appeared to depend more on administrative logic than on reported clinical familiarity with the therapy. The study portrays access as being determined primarily by system-level authorization logic.