Barriers and facilitators to implementation of intravenous cardiovascular treatments in ambulatory settings

Abstract

Aims

Intravenous (IV) therapies have transformed the management of various cardiovascular conditions in ambulatory patients. However, uptake of these therapies in ambulatory care settings has several barriers. In this systematic scoping review, we aimed to identify the barriers and facilitators that influence the implementation of current IV therapies in ambulatory settings.

Methods

We searched MEDLINE, Embase and CINAHL databases from inception to September 2023 for studies on barriers and facilitators of IV therapy uptake in ambulatory patients. We classified the identified factors and performed a thematic analysis.

Results

Fifteen studies, primarily conducted in North America and Europe, were included. Methodologies varied, precluding quantitative synthesis. Key barriers were identified across several levels. At the medication level, barriers included the need for multiple vials and lengthy preparation. Patient‐level barriers included adverse effects, infections, painful venous access and non‐adherence. Clinician‐level barriers included understaffing, time constraints and safety concerns. Institutional barriers ranged from staff or equipment shortages to liability concerns and complex logistics. Healthcare system barriers included financial constraints and limited care delivery services. Facilitators included evidence‐based indications, patient education and comfort, staff experience, guidance documents, safe settings, favourable insurance policies and supportive guidelines.

Conclusions

As novel IV treatments emerge, addressing barriers and leveraging facilitators preemptively can enhance the successful implementation of IV therapies and improve clinical outcomes in ambulatory settings.

Multi‐level barriers and facilitators to implementing ambulatory intravenous (IV) therapies.

Introduction

The landscape of cardiovascular disease management has been transformed by the emergence of intravenous (IV) therapies to treat ambulatory patients with transthyretin cardiac amyloidosis, ¹ iron deficiency, heart failure (HF), ² acute myocardial infarction and genetic conditions. These therapies offer potential advantages in efficacy and bioavailability over oral agents. For example, IV diuretics are used for decongestion in acute HF and also in advanced HF with resistance to oral diuretics. ³ IV iron therapy is more effective than oral iron for treating iron deficiency in chronic HF. ⁴

Administering IV therapies in ambulatory settings requires viable funding schemes, appropriate facilities, trained personnel and care co‐ordination, which may not be readily available. Patient‐related factors such as treatment burden and travel requirements may also play a role in uptake. ⁵ Experiences in the delivery of non‐cardiovascular IV therapies such as daily antibiotics or intermittent chemotherapy could potentially be applied to the delivery of IV cardiovascular therapies. A broad understanding of barriers and facilitators could inform the design of healthcare models to deliver IV cardiovascular therapies to ambulatory patients. Thus, in this systematic scoping narrative review, we aimed to identify barriers and facilitators influencing the uptake of IV therapies in ambulatory settings.

Methods and analysis

Study design

We conducted a systematic scoping review using an established methodological framework. Our study was conducted and reported based on the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses modified statement for scoping reviews (PRISMA‐ScR) standards. ⁶

Data extraction and synthesis

Two independent reviewers (M.B.J. and I.O.) screened titles and abstracts, followed by full‐text articles. Disagreements were resolved by consensus or third reviewer (H.G.C.V.).

We used a standardized form to extract publication details (year, journal and authors), study design, country/countries where IV care was delivered, healthcare setting (e.g., clinic, pharmacy, home and hospital), type of IV therapy, and barriers and facilitators. We described barriers and facilitators at the medication, patient, clinician, institution and healthcare system level and synthesized the results narratively. A quantitative analysis was not feasible due to significant methodological heterogeneity between the studies.

Results

A total of 360 titles and abstracts produced from the systematic search, including 26 hand‐selected articles from the supplementary literature search, were assessed for eligibility. Of the 360 articles, 296 were excluded on the basis of title and/or abstract review. We assessed 64 full‐text articles and abstracts, of which 15 met eligibility criteria (Figure 1). Details on each of the 15 studies are provided in Table S1.

Figure 1.

PRISMA flow diagram of studies included in the systematic scoping review. IV, intravenous.

Characteristics of included studies

The studies included in this review were published between 2008 and 2023 and carried out in the following countries: Australia (n = 2), Germany (n = 1), Ireland (n = 1), Malawi (n = 1), Norway (n = 1), Sweden (n = 1), the United Kingdom (n = 3) and the United States (n = 5).

The types of IV therapies included iron (n = 5), diuretics (n = 4), IV C1 esterase inhibitor (human) (n = 1), blood products (n = 2), antibiotics (n = 2) and thrombolytics (n = 1).

Results pertaining to barriers and facilitators were obtained from cohort studies (n = 6), a cluster randomized trial (n = 1), a systematic review (n = 1), a review (n = 2), an online survey (n = 1), qualitative studies (n = 3) and a policy document (n = 1) (Table 1).

Table 1.

Summary of characteristics of included studies (n = 15).

	Number of studies (%)
Country
Australia	2 (13.3)
Germany	1 (6.7)
Ireland	1 (6.7)
Malawi	1 (6.7)
Norway	1 (6.7)
Sweden	1 (6.7)
The United Kingdom	3 (20.0)
The United States	5 (33.3)
Type of IV therapy
IV iron	5 (33.3)
IV diuretics	4 (26.7)
IV C1 esterase inhibitor (human)	1 (6.7)
Blood products	2 (13.3)
IV antibiotics	2 (13.3)
IV thrombolytics	1 (6.7)
Type of study
Systematic review	1 (6.7)
Review article	2 (13.3)
Cohort study	6 (40.0)
Online survey	1 (6.7)
Policy document	1 (6.7)
Cluster randomized controlled trial	1 (6.7)
Qualitative studies	3 (20.0)
Year of publication
2008–2012	2 (13.3)
2015–2019	6 (40.0)
2020–2023	7 (46.7)

Abbreviation: IV, intravenous.

Barriers and facilitators

This systematic scoping review identified 15 studies highlighting factors that facilitate or impede the uptake of cardiovascular IV in ambulatory patients (Box 1). We classified the barriers and facilitators at the medication, patient, clinician, institution and healthcare system level and synthesized the results narratively. Barriers and facilitators are outlined in Table 2 and in the graphical abstract.

Box 1 Methods.

• Research question: What are the barriers and facilitators of the uptake of intravenous therapies in ambulatory patients?

• Eligibility criteria:

  • Participants: healthcare professionals, ambulatory patients and caregivers
  • Intervention: IV cardiovascular therapies
  • Comparator: none
  • Outcomes: perceived barriers/facilitators

• Search strategy: With the help of a librarian, we conducted a comprehensive search across multiple databases such as PubMed, Embase, CINAHL and Scopus + grey literature. Keywords included the following: ‘Barrier’ OR ‘Obstacle’ OR ‘Hindrance’ AND ‘Facilitator’ OR ‘Enabler’ OR ‘Promoter’ AND ‘Intravenous’ OR ‘IV’ AND ‘patients’ OR ‘caregivers’ OR ‘family’ OR ‘carers’ AND ‘facilitators’ OR ‘barriers’ OR ‘perspectives’ OR ‘needs’ OR ‘expectations’ AND ‘Acute’ AND ‘Ambulatory’ OR ‘Outpatient’ AND ‘Cardiovascular care’ OR ‘Heart care’. We supplemented the systematic literature search by hand‐searching reference lists of included studies or relevant reviews to ensure that no key studies were missed. We also explored grey literature sources such as conference proceedings, theses and government reports. In addition, we searched for grey literature for unpublished data or reports.

• English‐language publications from inception to September 2023

Table 2.

Barriers and facilitators to the uptake of IV therapies in ambulatory patients (15 studies).

Level	Barriers	Facilitators
Medication	Need for multiple vials	Evidence‐based clinical indication
	Longer preparation time
Patient	Suboptimal home safety and cleanliness (home infusion)	Patient engagement in decision‐making
	Adverse drug effects	Patient education or knowledge about intravenous medication
	Intravenous‐related infections	Perceived comfort during infusion
	Patient anxiety about home intravenous therapy
	Non‐adherence to treatment
	Difficult or painful venous access
Clinician	Concerns about the safety profile of intravenous medication	Clinician education/training
	Time constraints	Perceived utility
	Understaffing	Experience with intravenous therapy
Institution	Liability concerns	Guidance documents for intravenous therapy
	Staff shortages	Availability of stock and logistics
	Equipment shortages
	Triage delays
	Logistical complexity in obtaining access to the therapy or administering the infusion
Healthcare system	Cost and financial barriers	Existing practice policies and guidelines
	Inadequate access to services	Insurance coverage for intravenous therapy

Medication level

The reported barriers were the need for multiple vials and longer preparation time. The reported facilitator was clinical indication.

Patient level

The reported barriers were adverse drug effects, venous infections, difficult or painful venous access, anxiety, non‐adherence to treatment and reduced mobility. For those receiving home infusions, suboptimal home safety or cleanliness was a barrier. The frequently reported facilitators were patient engagement in decision‐making, education or knowledge about the IV medication, and comfort during the IV infusion.

Clinician level

The reported barriers were concerns about safety profile of the IV medication, lack of qualified staff and time constraints. The reported facilitators were practitioner education or training, experience with IV cannulation and perceived utility.

Institution level

Barriers included liability concerns, staff shortages, equipment shortages or malfunction, logistical complexity in obtaining access to or administering the medication, and triage delays. The reported facilitators were guidance documents for IV infusion and availability of stock and logistics.

Healthcare system level

The commonly reported barriers were cost and financial barriers, along with limited services to deliver the therapy. The reported facilitators were existing practice policies, guidelines and insurance coverage to support the IV therapy.

A roadmap for implementation

In the absence of evidence from implementation strategy trials, recommendations in this document are aimed at overcoming the barriers and leveraging the facilitators described in our study. Approaches to implementation can be guided by processes and theoretical frameworks described previously. ⁷

Knowledge dissemination

A well‐designed trial clearly demonstrating a sizeable treatment effect on clinically relevant endpoints is pivotal in shaping guideline recommendations in favour of a treatment. Knowledge dissemination of trial results through multimedia platforms can increase reach and engage broad groups of knowledge users. Tools targeted to decision‐makers, clinicians and patients can foster a better understanding of trial results to fill the knowledge gaps that were described as barriers in this study. ⁸ Such tools could include policy briefs, digital guideline summaries, apps for clinical use, electronic health record alerts, summaries for patients, and digital tools or nudges to patients. ⁷ , ⁹

Education and training

Training programmes for both patients and their caregivers and clinicians can play an important role in the uptake of IV therapies. These programmes can provide an overview of clinical indications and potentialadverse drug effects; for home care patients, they can also provide tips to manage infusion pump alarms or malfunctions and challenging venous access. Patient engagement in decision‐making can enhance adherence and satisfaction with care.

On the clinician side, comprehensive training on procedures such as IV cannulation, venipuncture and the maintenance of vascular access devices could mitigate healthcare provider‐level barriers. Further, continuous training and education on current best practices and specific protocols pertaining to IV therapy administration are crucial for ensuring competence among healthcare staff.

Services and equipment

Following the initial infusion in the hospital, existing home care services, ambulatory clinics or hospital day units may be leveraged to deliver IV treatment. Clear protocols should be developed to guide dosing, infusion therapy and management of adverse effects. ¹⁰ This standardizes practice, minimizes potential errors and ensures alignment with best practices.

Digital referral systems for home or ambulatory clinic care may streamline the uptake of IV therapies. Measurement and feedback mechanisms can help improve staffing: workload ratio, quality of service and workflow. Smart infusion systems and electronic drug dispensing systems can minimize medication errors and alleviate clinician burden. ¹¹

Medication cost and access

Regulatory approval does not always translate to treatment access or payer coverage. Economic evaluations—including cost‐effectiveness analyses—can help guide payer or insurance company decision‐making around coverage. ¹² Affordability and cost‐effectiveness vary across jurisdictions, and the decision regarding pricing is important in the eventual uptake of the therapy.

Development for a market, a reliable and efficient supply chain, and logistical simplicity in stock replacements and storage can ensure timely access to IV therapies; this is crucial in settings where delays can have significant adverse effects on patient outcomes. ³

Conclusions

In this systematic scoping review that included 15 studies, there were several multi‐level barriers to and facilitators of implementing IV therapies in ambulatory patients. Perceived facilitators included user‐friendly drug preparation, tolerability of the drug, safety of the setting, education and comfort of the patient, adequately trained staff, adequate time allocated to staff for work, adequate equipment, logistical ease of ordering the IV medication, adequate guidance manuals for administering the medication, guidelines or evidence to support the medication, and funding of services to administer the IV medication. Practice policies facilitated uptake, whereas high cost and limited access to services posed challenges. With a growing landscape of novel treatments requiring IV administration, understanding challenges and opportunities is crucial. Preemptively addressing the barriers and capitalizing on facilitators can enhance the success of implementation efforts and improve clinical outcomes.

Conflict of interest statement

A.S. is employed by CSL Behring. C.M.G. receives funding from CSL Behring, Janssen Pharmaceuticals, Johnson & Johnson Corporation and SCAD Alliance. He also reports consulting for Angel Medical Corporation, AstraZeneca, Bayer Corporation, Bioclinica, Boston Clinical Research Institute, Boston Scientific, Bristol Myers Squibb, Caladrius Biosciences, Cardiovascular Research Foundation, CeleCor Therapeutics, CSL Behring, Cytokinetics, Daiichi Sankyo, Duke Clinical Research Institute, EXCITE International ($0 received), Fortress Biotech, Gilead Sciences, Inc., Inari, Janssen Pharmaceuticals, Johnson & Johnson Corporation, MashUpMD, MD Magazine, MedImmune, Medtelligence, Merck, MicroPort, Micodrop LLC, Miracor, MJ Health, Novartis, NovoNordisk, Paratek, PERT Consortium, Pfizer, PhaseBio, PHRI, PLx Pharma, Revance Therapeutics, SCAI, Solstice Health/New Amsterdam Pharma, Somahlution/Marizyme, Vectura, WebMD and Women As One. He has equity in Absolutys, nference, Dyad Medical and Fortress Biotech and has received royalties as a contributor to UpToDate in Cardiovascular Medicine. H.G.C.V. receives research support from the Canadian Institutes of Health Research and Heart and Stroke Foundation of Canada and education programme funding from Boehringer Ingelheim and Novartis. She serves on clinical trial executive committees for Bayer, Medtronic, and Novo Nordisk. J.L.J. is a trustee of the American College of Cardiology, a board member of Imbria Pharmaceuticals and director at Jana Care; has received grant support from Abbott Diagnostics, Applied Therapeutics, Innolife, Novartis Pharmaceuticals and Roche Diagnostics and consulting income from Abbott, Abiomed, Beckman Coulter, Janssen, Merck, Novartis, Prevencio and Roche Diagnostics; and participates in clinical endpoint committees/data safety monitoring boards for Abbott, AbbVie, Bayer, CVRx, Janssen, Pfizer and Takeda. M.C.B. reported fees from Bristol Myers Squibb and Pfizer and others from Merck Sharp & Dohme, CSL Behring, Vifor and Boehringer Ingelheim outside the submitted work. M.B.J., I.O. and S.K. report no conflicts of interest.

Supporting information

Table S1. List of included studies (n = 15).

Jalloh, M. B. , Osoro, I. , Januzzi, J. L. , Shaunik, A. , Bahit, M. C. , Korjian, S. , Gibson, C. M. , and Van Spall, H. G. C. (2025) Barriers and facilitators to implementation of intravenous cardiovascular treatments in ambulatory settings. ESC Heart Failure, 12: 695–700. 10.1002/ehf2.15076.