Table 2.

Taxonomy of reasons for non-prescribing – definitions and illustrations

Category / Subcategory	Definition	Illustration
1. Adverse effects of drug therapy	Adverse clinical effects of drug therapy, including adverse drug reactions and drug contraindications	Hyperkalemia on ACE inhibitors
2. Non-adherence to therapeutic and monitoring plan	Improper use of medications, including non-adherence, improper dose and dosing frequency (e.g., with risk of overdose), and problems with followup monitoring. Often discussed as a safety issue
Cognitive capacity	Patient confusion about proper use or monitoring of medications	Cognitive impairment
Access to care and environmental constraints	Environmental and systems factors impacting proper use or monitoring of medications	Lack of health insurance impacting ability to pay for medications
Patient understanding *	Challenges to communication between patient and their physician or the health system	Poor health systems literacy impacting patient ability to obtain follow-up care
Transitions of care *	Challenges to physician-physician communication as patient is transferred from one clinician or care setting to another	Discharge from inpatient to outpatient care with fear that patient will not receive follow-up labs after being started on ACE inhibitor
Cross-cutting and non-specific barriers	Reason involving more than one of the above sub-categories, or sufficiently general to prevent classification into a specific sub-category	Cognitive impairment in absence of caregiver to assist with medication administration
3. Patient preferences	Patient reluctance to take medications due to preferences, health beliefs, and goals of care.
Patient preferences and beliefs	Same as general category definition	Patient refusal to add more medications to current regimen
Patient understanding *	As above (see “non-adherence to therapeutic and monitoring plan” category)	Language barriers that impede clinician attempts to understand and overcome patient reluctance to use medications
Cross-cutting and non-specific barriers	Reason involving more than one of the above sub-categories, or sufficiently general to prevent classification into a specific sub-category	Non-English-speaking patients with non-scientific approach to medicine
4. Co-management and transitions of care	Patient receiving care from more than one physician or health system
Co-management in ongoing care	Delegation of responsibility in ongoing care of a patient, or other failure to coordinate ongoing care.	Primary care physician defers responsibility for heart failure care to patient’s cardiologist
Transitions of care *	As above (see “non-adherence to therapeutic and monitoring plan” category)	As above
Cross-cutting or non-specific barriers	Reason involving more than one of the above sub-categories, or sufficiently general to prevent classification into a specific sub-category	Receiving physician not understanding reasons why patient is not on a recommended drug
5. Prioritization and patient benefit	Prioritization among competing demands for time, and perceived benefit of the guideline-recommended intervention
Prioritization and time limitations	No long term reason not to prescribe, but cannot practically address recommended medications until other issues have stabilized	Acute medical or psychiatric illness
Limited or uncertain benefit	Uncertainty that patient will derive net benefit from drug	Patient with limited life expectancy; patient with borderline or changing ejection fraction

^*These sub-categories are shared between 2 categories.