The problem of clinical non-adherence
Beta blockers have been a cornerstone of heart failure treatment for decades. First developed in the 1960s, they are supported by extensive clinical evidence and recommended by leading professional societies, including the American College of Cardiology, as well as advocacy organisations such as the American Heart Association.
Landmark trials have consistently shown that beta blockers lower heart rate, improve cardiac function, and significantly reduce morbidity and mortality in patients with heart failure caused by impaired cardiac contraction. They are also inexpensive and widely available.
Yet, despite this long-standing evidence base, recent research reveals a persistent and troubling gap between guideline recommendations and real-world practice. An analysis of more than 100 million US medical claims from 1st July 2022 through 30th June 2024 found that nearly one in three eligible heart failure patients was not receiving a guideline-recommended beta blocker.
The data also revealed striking geographic variation. The best-performing states – Washington , Minnesota, and South Dakota – had the lowest rates of missed treatment, with approximately 21% of eligible patients not receiving appropriate therapy. In contrast, states such as Arkansas (36%), California (35%), and Louisiana (34%) saw more than one-third of eligible patients go untreated. While the analysis did not explore the underlying causes of these state-by-state differences, the disparities themselves are difficult to ignore.
This gap in care has profound implications. Heart failure currently affects an estimated 6.7 million Americans, a number projected to rise to 11.4 million by 2050 as the population ages. Beyond the human toll, the economic burden is substantial: in 2020 alone, heart failure accounted for approximately $32 billion in direct and indirect costs, with projections reaching as high as $858 billion by mid-century.
Greater adherence to evidence-based prescribing guidelines for beta blockers represents a clear opportunity to improve patient outcomes while reducing avoidable downstream costs. While not every patient is an appropriate candidate and not all beta blockers are indicated for heart failure, the weight of evidence overwhelmingly supports broader, more consistent adoption of guideline-recommended therapy.
Obstacles to adherence
Although patient preference and medication persistence play a role, the primary driver of underuse is physician non-prescribing. While the recent claims analysis did not examine the specific reasons behind these decisions, prior research offers important insight into why guideline adherence remains uneven.
The American College of Cardiology has identified many reasons for non-adherence. These include patient factors (e.g., poor health, literacy, depression, cognitive impairment), socioeconomic factors (e.g., limited access to pharmacy, lack of social support), and health system factors (e.g., poor communication, siloed care, difficulty navigating patient assistance programmes).
Improving adherence to guideline-directed medical therapy in heart failure will require a coordinated effort across multiple fronts. Among these, patient support and system-wide policy reforms will be key.
The cost of non-adherence
The US healthcare system spends an estimated $400 billion annually on unnecessary or low-value care that provides little benefit and may expose patients to harm and out-of-pocket expenses. In addition to consuming scarce financial and clinical resources, non-recommended care increases patient risk and contributes to preventable complications and downstream utilisation.
A landmark Journal of American Medical Association study showed that the US spent approximately twice as much on healthcare – 17.8% of GDP in 2016 – as other high-income countries, but had the worst health outcomes, including the lowest life expectancy and the highest infant mortality.
Improving adherence through insight and action
Meaningful improvement begins with measurement. Healthcare organisations must first understand the extent and nature of non-adherence within their own systems, ensuring that institutional policies align with current standards and that clinicians are aware of them.
At scale, however, accurately assessing adherence is no small task. Large health systems may need to evaluate thousands of providers and hundreds of thousands of procedures, treatments, and prescriptions. Such an undertaking typically exceeds the capacity of internal teams.
Advanced clinical analytics conducted by an expert third party offers a practical and scalable solution. By analysing insurance claims against nationally recognised clinical guidelines, healthcare organisations can gain a clear, objective view of where care aligns with evidence and where opportunities for improvement exist. These insights should start at the individual physician level and can be reported out and analysed in a range of ways: by specialty, group/TIN level, or across an entire health system, enabling targeted, constructive interventions.
Armed with reliable, actionable data, organisations can support clinicians through focused education, performance transparency, and the removal of systemic barriers – driving sustained improvements in adherence without resorting to punitive measures. The result is more consistent, high-value care that benefits all stakeholders in the US health system – patients, providers, and payers.
About the author
Rich Klasco, MD, is chief medical officer of Motive Medical Intelligence, a healthcare data analytics company dedicated to value-based care and individual physician measurement.
