NR 715 Week 2 Practice Problem Statement Example

Practice Problem Statement: Unexplained Decisions Not to Titrate Heart Failure Medicines at Eligible Visits in a General Cardiology Clinic

Student Name

College of Nursing, Chamberlain University

NR 715: Scientific Underpinnings

Instructor Name

Month Day, Year

Practice Problem Statement: Unexplained Decisions Not to Titrate Heart Failure Medicines at Eligible Visits in a General Cardiology Clinic

Population and Setting

The population is adults whose heart failure has a reduced ejection fraction (HFrEF), defined as a most recent ejection fraction of 40% or less, who are followed in the general cardiology clinic of a four-office suburban cardiology group. These patients are not seen in the group's specialty heart failure program; they are followed by five physicians and three nurse practitioners alongside patients with other cardiac conditions. On 30 September 2026 the clinic followed 612 such adults. Their median age was 71, and 38% also had chronic kidney disease recorded.

The Observed Indicator

The indicator is the proportion of titration-eligible visits that end with no change in guideline-directed medical therapy and no documented reason. The practice defines a visit as titration-eligible when the patient is not at the target dose of at least one of the four recommended drug classes, a beta-blocker, a renin-angiotensin system inhibitor, a mineralocorticoid receptor antagonist and a sodium-glucose cotransporter 2 inhibitor, and when the visit record shows a systolic pressure of at least 100 mm Hg, a potassium of 5.0 mmol/L or lower and an estimated glomerular filtration rate of at least 30 mL/min/1.73 m2, with no recorded symptomatic hypotension.

From 1 October 2025 to 30 September 2026, the clinic recorded 1,148 visits by these patients, of which 704 were titration-eligible. At 81 of the 704, a drug was started or increased. At 52, nothing changed and a reason was documented, most often that the patient asked to wait or had an upcoming procedure. At the remaining 571, nothing changed and no reason was recorded. The observed level is therefore 571 of 704, or 81.1% of eligible visits.

The Expected Level

The 2022 national heart failure guideline expects that patients with reduced ejection fraction will be moved toward target doses of each class as tolerated, which in practice means that an eligible visit should end either with a change or with a stated reason not to make one (Heidenreich et al., 2022). In January 2026 the practice's quality committee adopted a first-year expectation that no more than 40% of eligible visits would end with neither. The gap is the distance between the observed 81.1% and the expected 40%: 41 percentage points, or about 289 visits a year at the current volume.

The expected level was set by the practice, not borrowed. National registry work shows that most outpatients with this condition are not on target doses and that dose increases are uncommon across a year of follow-up (Greene et al., 2018), so the clinic's figure is not unusual. Being typical is not the same as meeting the standard the practice has set for itself.

How Firm the Observed Level Is

The structured count depends on clinicians using the reason field, and some write their reasons in the free-text plan instead. To check, the project lead read the full notes of 60 randomly chosen no-change visits from the 571. Four contained a reason in free text that the structured field had missed: two patients asked to wait, one had lightheadedness on standing that was not recorded as hypotension and one was awaiting a dental extraction. Applied to all 571, that suggests about 533 visits truly ended with no change and no reason anywhere in the record, or about 75.7% of eligible visits. The gap to the 40% expectation is still about 36 points. The statement uses the structured figure of 81.1% for comparison over time, because it is the one the clinic can produce every month, and reports the chart-review estimate beside it so that no reader mistakes a recording habit for the whole problem.

Significance in Consequences

The 612 patients had 149 heart failure hospitalizations in the same twelve months. The group's accountable care organization report priced each at about $13,800 in payments, roughly $2.06 million in total. Not every admission can be traced to a dose that was not raised, and this statement does not claim that. What can be said is that the drug classes in question reduce hospitalization in trials, that patients below target doses forgo part of that benefit and that each unexplained no-change visit postpones the next opportunity by the length of the follow-up interval, a median of 91 days in this clinic. A patient eligible at four visits in a year who leaves each one unchanged has lost a year of titration. Timing appears to matter: in a trial of rapid, protocol-driven up-titration in the weeks after a heart failure admission, patients randomized to early titration had fewer deaths or heart failure readmissions at 180 days than those receiving usual care (Mebazaa et al., 2022). That trial studied a different moment in the illness, but it suggests that delay is not neutral.

There is also a cost the clinic bears directly. Patients who are hospitalized return for post-discharge visits that take the place of routine follow-up, which lengthens the wait for new referrals. The clinic's average wait for a new heart failure referral rose from 19 days to 31 days over the year.

What This Statement Does Not Say

It does not say why the gap exists. The obvious explanations, short visits, missing labs, clinicians' concern about low blood pressure or kidney function, patients' reluctance and drug costs, are all candidates, and an earlier look at visit length found that forty-minute visits ended with unexplained no-change almost as often as twenty-minute ones. Settling the cause is the work that follows this statement. The pattern already has a name in the literature, clinical inertia, but a name is not an explanation; the original description proposed several causes and left their weight in any given practice to be measured (Phillips et al., 2001). It also does not propose an intervention. Naming a fix now would decide the cause before it has been examined.

Scope

The problem is drawn at the level of the visit, because that is where the decision is made and recorded. It excludes patients followed in the specialty heart failure program, patients with ejection fraction above 40% and visits in the 30 days after a hospital discharge, when changes are often made by the inpatient team. It does not include whether patients take the medicines prescribed, which the clinic cannot measure at the visit.

The Answerable Question

Among adults with HFrEF seen in a general cardiology clinic, what factors at the level of the clinician, the visit and the patient are associated with titration-eligible visits that end with no change and no documented reason?

References

Greene, S. J., Butler, J., Albert, N. M., DeVore, A. D., Sharma, P. P., Duffy, C. I., Hill, C. L., McCague, K., Mi, X., Patterson, J. H., Spertus, J. A., Thomas, L., Williams, F. B., Hernandez, A. F., & Fonarow, G. C. (2018). Medical therapy for heart failure with reduced ejection fraction: The CHAMP-HF registry. Journal of the American College of Cardiology, 72(4), 351-366. https://doi.org/10.1016/j.jacc.2018.04.070

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. https://doi.org/10.1161/CIR.0000000000001063

Mebazaa, A., Davison, B., Chioncel, O., Cohen-Solal, A., Diaz, R., Filippatos, G., Metra, M., Ponikowski, P., Sliwa, K., Voors, A. A., Edwards, C., Novosadova, M., Takagi, K., Damasceno, A., Saidu, H., Gayat, E., Pang, P. S., Celutkiene, J., & Cotter, G. (2022). Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): A multinational, open-label, randomised, trial. The Lancet, 400(10367), 1938-1952. https://doi.org/10.1016/S0140-6736(22)02076-1

Phillips, L. S., Branch, W. T., Cook, C. B., Doyle, J. P., El-Kebbi, I. M., Gallina, D. L., Miller, C. D., Ziemer, D. C., & Barnes, C. S. (2001). Clinical inertia. Annals of Internal Medicine, 135(9), 825-834. https://doi.org/10.7326/0003-4819-135-9-200111060-00012