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Running head: PRIMARY CARE INITIATION OF SGLT2I 1

PRIMARY CARE INITIATION OF SGLT2I 21

Primary Care Initiation of SGLT2 Inhibitors in Heart Failure Patients

Primary Care Initiation of SGLT2i in Heart Failure Patients

Heart failure (HF) is a progressive chronic condition that is characterized by the heart ineffectively pumping blood and oxygen to support vital organs and the rest of the body (Centers for Disease Control and Prevention [CDC], 2025). In the United States alone, approximately over 6 million adults are affected by HF, making the disease one of the largest public health problems in the United States (Butler & Rich, 2024). Moreover, heart failure is a condition that is rarely dealt with in isolation (Butler & Rich, 2024). Over 70% of those affected have comorbidities, which include chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM), both of which are serious chronic conditions that share overlapping risk factors with heart failure and further exacerbate the burden of HF (Butler & Rich, 2024).

Since 2019, sodium-glucose cotransporter inhibitors (SGLT2i) have become breakthrough therapy in the management of HF. Primarily developed for the treatment of T2DM, SGLT2i were shown to have cardioprotective effects and significantly decrease the rate of hospitalizations related to HF (Butler & Rich, 2024). In support of evidence from large-scale clinical trials, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA), deemed initiation of SGLT2i as evidence-based guidelines for the treatment of HF in 2022 (Heidenreich et al., 2022).

Although newly established guidelines support the use of SGLT2i in HF, initiation of these medications within primary care remains suboptimal (Jiron Vindas et al., 2026). Many diagnosed with HF are not on these medications, especially in primary care settings. Multiple barriers, including delayed diagnosis of HF, inadequate dissemination of novel guidelines, limited provider familiarity with SGLT2i, hesitancy in prescribing them in patients on multiple concomitant medications, and uncertainty regarding initiation and monitoring may contribute to inadequate SGLT2i initiation in primary care (Butler & Pessah-Pollack, 2024). Because primary care providers (PCP) are often the first point of contact for patients with chronic health conditions, such as cardiovascular disease and HF, delay in initiating evidence-based therapy can lead to poorer health outcomes, disease progression, and increased mortality and morbidity of the population (Butler & Anderson, 2024; Evans et al., 2022).

The purpose of this paper is to systematically examine the importance of SGLT2i initiation in HF patients within a primary care setting by conducting a systematic review of the literature. Barriers to SGLT2i initiation will be discussed. Additionally, the impact of social determinants of health (SDOH) on treatment initiation and adherence will be explored. The Iowa Model of Evidence-Based Practice (EBP) will be applied as theoretical framework, and the role of the advanced practice registered nurse (APRN) will be emphasized in addressing these challenges. Finally, the implementation and evaluation of a nurse practitioner (NP)-led quality improvement protocol inspired by recent implementation strategies of SGLT2i initiation in primary care will serve as the proposed intervention.

Pathophysiology and Disease Progression

Heart failure occurs when the heart cannot pump blood efficiently to meet the body’s physiological and metabolic needs. This occurs due to several causes, such as coronary artery disease, myocardial infarction, diabetes, hypertension, arrythmias, and valvular heart disease resulting in the alteration of the structure and function of the heart and myocardium (American College of Cardiology, [ACC] 2025a; Golla et al., 2024; Heidenreich et al., 2022). This alteration eventually results in impaired ventricular filling, reduction in cardiac output, and compensatory responses by the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) (Golla et al., 2024). Over time, these compensatory responses contribute to cardiac remodeling, fluid retention, and worsening progression of the disease (Golla et al., 2024).

The disease course of HF is chronic and progressive. Initially, patients experience mild symptoms such as fatigue and dyspnea with exertion. Throughout the course of HF, symptoms worsen and include orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, progressive fatigue, and decreased exercise tolerance (Heidenreich et al., 2022). The progressive nature of HF results in exacerbations, repeated hospitalizations and an eventual decline in functional capacity. Heart failure exacerbations can occur due to infection, medication non-adherence, dietary indiscretion, and unmanaged comorbid conditions. With each exacerbation, damage to the myocardium will affect the function of the heart and eventually reduce cardiac reserve. Because HF affects the heart, which is central to all the other organs, the advancement of the disease leads to multi-organ dysfunction and increased mortality risk.

Operational Definitions

Reference Terms

Heart failure. Heart failure is a progressive chronic health condition where the heart ineffectively pumps oxygen-rich blood to the rest of the body. The main types of HF are HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Other types include HF with mildly reduced ejection fraction and HF with improved ejection fraction. The ACC and AHA have defined the four stages of HF, Stages A through D, based on structural progression, as presented in Table A1 (Golla et al., 2024). Furthermore, to delineate the functional capacity of patients diagnosed with HF in Stage C or D, the New York Heart Association (NYHA) Classification of Heart Failure was established as a subjective tool for clinicians, Class I through IV, as presented in in Table A2 (Golla et al., 2024). The NYHA Classification of HF is useful in determining the trajectory of the late stages of HF and symptom management when it comes to palliative and end-of-life care.

Ejection fraction. Ejection fraction (EF) is a measure of how much blood the heart, specifically the left ventricle, is pumping out with each beat in the form of a percentage (ACC, 2025b). The normal EF for a healthy adult is greater than 50%. Ejection fraction helps categorize what type of HF a person has and aids the provider in determining the appropriate treatment. A non-invasive way to determine the EF of the heart is by an ultrasound of the heart, which is called a transthoracic echocardiogram.

Heart failure with reduced ejection fraction. Heart failure with reduced ejection fraction (HFrEF) is defined as HF with an EF of 40% or lower. This means that the left ventricle of the heart loses its ability to contract effectively, leading to the reduction of EF and ultimately inadequate systemic circulation (ACC, 2025b). Previously, HFrEF was termed systolic heart failure. Currently, evidence-based treatment for this type HF includes four classes of medications to help improve the function of the heart and reduce mortality known as guideline-directed medical therapy (ACC, 2025b).

Heart failure with preserved ejection fraction. Heart failure with preserved ejection fraction (HFpEF) is defined as HF with an EF of 50% or greater, meaning the heart’s ability to pump blood into the rest of the body is “preserved” (ACC, 2025b). Although the EF is maintained numerically, the heart has difficulty relaxing and can stiffen. Symptoms such as shortness of breath can present as excess fluid in the lungs, abdomen, or legs. This is caused by cardiac dysfunction due to abnormal left ventricle filling pattern and elevated filling pressures (Borlaug, 2026). Previously, HFpEF was termed diastolic heart failure, however, the presence of diastolic dysfunction on an echocardiogram is neither specific nor sufficient to make a diagnosis of HFpEF (Kittleson et al., 2023).

Sodium-glucose cotransporter 2 inhibitors. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a class of medications that have been recommended by the ACC, AHA, HFSA as guidelines for treatment of HF, specifically, dapagliflozin, empagliflozin, and sotagliflozin. Initially, these class of medications have been used for the treatment of T2DM due to its glycosuria and cardioprotective effects (Butler & Pessah-Pollack, 2024). SGLT2i have shown to reduce cardiovascular death, worsening HF, and hospitalizations related to HF in six major randomized controlled trials from 2019 to 2022 (Butler & Rich, 2024). Notable side effects of SGLT2i include genitourinary infections due to glucose being excreted through the urine. Serious adverse reactions include Fournier’s gangrene and diabetic ketoacidosis (DKA).

Guideline-directed medical therapy. Guideline-directed medical therapy (GDMT) was first established in 2013 by the ACC and AHA to standardize the optimization of pharmacological therapy in patients with HF and promote reduced morbidity and mortality (Ward & Prasad, 2025). Overall, GDMT for HF has evolved over time with the emergence of clinical trials and evidence-based therapies. The GDMT for HFrEF are based on four pillars of medication classes: beta blockers, mineralocorticoid receptor antagonists (MRAs), RAAS inhibitors, and SGLT2i. The current GDMT for HFpEF are SGLT2i and symptom management.

Class of recommendation. Established by the ACC and AHA, class of recommendation indicates the strength of recommendation weighing out benefit versus risk. There are three classes of recommendations, where Class 1 indicates a strong recommendation and Class 3 indicates harm, as presented in Figure A1. Recommendations are applied to clinical strategies, interventions, treatments, or diagnostic testing in patient care (Heidenreich et al., 2022).

Primary care. This healthcare setting is defined as patient care provided to the adult, family, and gerontological populations and excludes acute care, inpatient, and institutional settings.

Background and Significance

Prior to SGLT2i as dedicated treatment of HF, those affected by the disease had a five-year mortality rate of 75% (Shah et al., 2017). Furthermore, there were no survival-prolonging drugs that have been approved for the treatment of HF. The 2022 ACC/AHA/HFSA guidelines for the management of HFrEF recommend initiation of SGLT2i due to its reduction in worsening HF and cardiovascular mortality (Butler & Rich, 2024; Heidenreich et al., 2022). Furthermore, updated 2023 ACC decision pathways emphasized SGLT2i initiation, not only for HFrEF, but also for HFpEF (Heidenreich et al., 2022; Kittleson et al., 2023). These recommendations further emphasize the expanding role of SGLT2i across the spectrum of HF care.

During the late 2010s and the early 2020s, six landmark clinical trials established the efficacy of SGLT2i. The clinical trials that led the ACC, AHA, and HFSA to establish guidelines in 2022 started with trials of dapagliflozin and empagliflozin in patients with HFrEF and HFpEF. Specifically, HFrEF trials had at least a 25% reduction in cardiovascular (CV) death or HF hospitalizations and an overall 30% reduction in worsening HF irrespective of T2DM diagnosis (Butler & Rich, 2024). Trials for HFpEF also had a reduction of at least 18% in CV death or worsening HF (Butler & Rich, 2024). Additionally, the guidelines now include SGLT2i as Class 1 recommendation with high-quality evidence as GDMT for HFrEF (Heidenreich et al., 2022). Conversely, SGLT2i were categorized as a Class 2a recommendation for the management of HFpEF (Heidenreich et al., 2022). The ACC anticipates the class of recommendation of SGLT2i for the management of HFpEF to be a Class 1 recommendation (Kittleson et al., 2023), following suite to the European Society of Cardiology’s Class 1 recommendation of SGLT2i in patients with HFpEF (Crispino et al., 2025).

The prevalence of HFpEF has increased due to the aging population and preceding metabolic disorders and risk factors of HF, such as obesity and T2DM. HFpEF now accounts for more than 50% of cases of HF (Kittleson et al., 2023). The lifetime risk of HFpEF is estimated at about 19.3% which is greater than the lifetime risk of HFrEF of 11.4% (Golla et al., 2024). Additionally, women are at higher risk of developing HFpEF due to their higher EFs and more preserved left ventricular strain (Kittleson et al., 2023).

Identification of HF and implementation of GDMT is foundational to HF survival rates. Because HF is largely a clinical diagnosis with presenting symptoms such as shortness of breath, edema, and fatigue, it can be misdiagnosed in as many as 69% of cases (Butler & Anderson, 2024). Although evidence-based guidelines recommend early initiation of SGLT2i therapy at the primary stages of suspected HF, especially in those with T2DM and CV disease or those at high risk for CV disease (Heidenreich et al., 2022, p. e919), translation of these recommendations into routine primary care practice remains limited. Gaps in care can not only endanger individual health outcomes but also increase mortality and morbidity of the population as a whole (Butler & Anderson, 2024). These gaps in identification of HF and implementation of GDMT highlight an important opportunity for PCPs and NPs to improve adherence to these medications and optimize CV outcomes among HF patients.

Review of Literature

This review of literature investigates the research of SGLT2i initiation in HF patients in primary care. Specifically, the following themes were examined in this research synthesis: (a) the efficacy of SGLT2i in heart failure, (b) the evidence-to-practice gaps in primary care, (c) the barriers to initiation of SGLT2i in heart failure patients within primary care, and (d) implementation models of SGLT2i in primary care for heart failure patients. Also, limitations, gaps, and future recommendations from the identified literature will be discussed. Overall, the total studies included in the review (n=14) were from databases (n=9) and other sources (n=5), seen on the PRISMA diagram in Figure A2.

The databases used in the literature review were CINAHL Complete, MEDLINE with Full Text, Health Source: Nursing/Academic Edition, and Alt HealthWatch. The following keywords were identified: initiation, SGLT2 inhibitors, heart failure patients, and primary care. The studies that were examined were published within the past five years, 2021 to 2026. The search options investigated the full text of the articles and applied the search to equivalent subjects with Proximity search mode. The inclusion criteria consisted of Academic Journals, English language, and Peer Reviewed. One specific exclusion criterion was Book Reviews. The Boolean statement used for the query are as follows:

(SU (“Heart failure” or HFrEF or HFpEF or CHF or “ejection fraction”) or TI (“Heart failure” or HFrEF or HFpEF or CHF or “ejection fraction”)) AND (SU (outpatient* or ambulatory or clinic* or "primary care" or "general practice" or "family practice" or community or “internal medicine”) or TI (outpatient* or ambulatory or clinic* or "primary care" or "general practice" or "family practice" or community or “internal medicine”)) AND (SU (sodium-glucose cotransporter 2 inhibitor* or SGLT2 inhibitor* or empagliflozin or dapagliflozin or sotagliflozin or SGLT2i) or TI (sodium-glucose cotransporter 2 inhibitor* or SGLT2 inhibitor* or empagliflozin or dapagliflozin or sotagliflozin or SGLT2i)) AND (SU (Improv* or outcome* or well-being or "well being" or "life satisf*") or TI (Improv* or outcome* or well-being or "well being" or "life satisf*")) NOT TI (abstract* or symposi* or conference* or poster* or “annual meet*”)

Out of the records identified (n=158) from the search, records were screened for duplicates (n=19). Title and abstract screening were completed, and records were excluded manually (n=83) based on relevance to the research question. The full text of the initially screened articles was retrieved then later assessed for eligibility (n=48) and exclusion criteria. The total number of reports excluded (n=39) were based on articles identifying the wrong population, such as pediatric populations and populations focusing on a different disease process (n=10), the wrong setting, such as the hospital setting or setting not applicable to the United States primary care, such as those in China and Thailand (n=5), the wrong intervention (n=4), the wrong type of article (n=6) and other exclusion criteria (n=16) that did not directly address the research topic.

Additionally, the website, Google Scholar, was used in obtaining articles related to the topic of investigation along with snowballing related articles (n=19). The search statement for Google Scholar was the research question: What impact does initiation of SGLT2 inhibitors have on heart failure patients in primary care? Most of articles’ full text were retrieved and further examined for eligibility (n=17). The total number of reports excluded from other sources (n=12) were based on being the wrong type of article (n=9), guidelines more applicable to the background and significance (n=2), and not being peer reviewed (n=1).

Thematic Synthesis

Efficacy of SGLT2i in Heart Failure. As discussed in the introduction of this paper, HF is complex, high-burden disease process that rarely occurs in isolation (Butler & Rich, 2024). Many patients affected by the disease have comorbidities, such as T2DM and CKD, which, if not managed, amplifies the risk of worsening HF regardless of EF (Butler & Rich, 2024). The six landmark randomized clinical trials are evidence of the efficacy of SGLT2i in HF patients across the spectrum of EF. Butler and Rich (2024) discussed an overall 30% reduction in worsening HFrEF with dapagliflozin in the DAPA-HF study from 2019 and with empagliflozin in the EMPEROR-Reduced study from 2020, at least an 18 % reduction in worsening HFpEF with empagliflozin in the EMPEROR-Preserved study from 2021 and with dapagliflozin in the DELIVER study from 2022, and finally, a reduction in the risk of death from an cause in acute HF with sotagliflozin in the SOLOIST-WHF study from 2021 and with empagliflozin in the EMPULSE study from 2022. Due to the strength of these findings, clinical guidelines recommend SGLT2i as first-line treatment in all patients with HF, including those with HFrEF and/or HFpEF (Butler & Rich, 2024). Similarly, in several meta-analyses, SGLT2i showed at least a 23% reduction in CV death or first HF hospitalization and a 12% reduction in total mortality, which was consistent across EF types, diabetes status, age, and sex (Ahmad et al., 2021; Bodea et al., 2026; Gager et al., 2021). Moreover, in another meta-analysis by Bazoukis et al. (2021), SGLT2i’s safety profile was excellent with data demonstrating no excess DKA, acute kidney injury, severe hypoglycemia, or amputation risk in HF populations, in addition to being protective against serious adverse events.

With factors beyond the reduction of mortality, SGLT2i have shown to have cardioprotective effects without the diagnosis of T2DM, improve quality of life, and benefit across all age groups. Independent of its’ glucose-lowering effects, the pharmacological mechanism of SGLT2i reverses cardiac remodeling within six months of initiation which causes overall improvement in EF and reduction of vascular stiffness and calcification of the vascular system (Bodea et al., 2026; Jiron Vindas et al., 2026). Additionally, SGLT2i were examined in patient-centered outcomes by Bodea et al. (2026), demonstrating higher scores across HFpEF and HFrEF populations for clinically meaningful symptom relief, increased walking distance, and overall improved quality of life, using the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12). Lastly, empagliflozin in the EMPEROR-Preserved study from 2021 confirmed SGLT2i’s consistent benefit across all age groups, including HFpEF patients that were older than 80 years with no loss in effectiveness of the medication (Böhm et al., 2020).

Evidence-to-Practice Gaps in Primary Care. Given the strong evidence of efficacy of SGLT2i in HF patients, gaps in utilization rates in real world practice remain. Hussain et al. (2023) found that across 130 facilities in the United States, only 14.6% of 105,799 eligible patients with atherosclerotic cardiovascular disease (ASCVD), HF, and T2DM received SGLT2i. This shows that SGLT2i were highly underutilized. Specifically, most patients that were given an SGLT2i were those that were younger, have an existing HFrEF diagnosis, and have a higher HgA1c, a measurement to indicate T2DM status (Hussain et al., 2023). This suggests that those with HFpEF and older patients were being excluded from these medications that lead to opportunities of prevention of adverse CV events (Hussain et al., 2023). From the providers’ perspective, Khunti et al. (2022) found that prescription rates of SGLT2i varied among specialties, with cardiologists the lowest prescribers, endocrinologists the highest, and no mention of the percentage rate of primary care physician usage. This may be due to primary care physicians having fewer opportunities for education on the cardio-renal benefits of SGLT2i (Khunti et al., 2022).

Several authors focused on primary care as a central role in SGLT2i initiation and identified the gaps in care. From a primary care perspective, Evans et al. (2022) found that many patients with cardio-renal metabolic disease, such as patients with T2DM and CKD, are first managed by a PCP, making primary care a logical place for initiation of SGLT2i. Although this review was based in the United Kingdom, the authors emphasized the importance of implementing this life-saving medication within the primary care sphere (Evans et al., 2022). Notably, prior to an intervention to improve the initiation rates of SGLT2i for HF patients, Milos Nymberg et al. (2026) found that GDMT for HF was underutilized in 20.8% of patients studied at baseline, drawing attention to the evidence-to-practice gap even when guidelines had already been established.

Barriers to Initiation of SGLT2i in Primary Care. Now that gaps of SGLT2i initiation have been identified, barriers to initiation, including provider knowledge and confidence, patient characteristics, and system-level factors, need to be examined (Khunti et al., 2022). The lack of knowledge of the benefits of SGLT2i plays an important role. At a provider level, benefits of SGLT2i, such as its’ cardio-renal benefits, are not well understood (Khunti et al., 2022). Also, because of the diabetic origins of SGLT2i, Khunti et al. (2022) found that providers perceived SGLT2i as a diabetes-only medication and, interestingly, initiation of the medication was likely deferred to a specialist, such as a cardiologist or an endocrinologist. Another barrier at the provider level is the misconceptions of the safety of SGLT2i. Adverse effects such as DKA, hypoglycemia with concomitant use in insulin, urinary tract infections, and volume depletion are reasons for provider hesitancy, however the literature consistently shows that risk is deeply emphasized relative to the benefit, especially in HF patients (Khunti et al., 2022; Monzo et al., 2023). Additionally, the complexity of evolving label indications, with SGLT2i first being recommended for T2DM, then HFrEF, then HFpEF, then CKD, have resulted in confusion and unclear understanding to PCPs (Evans et al., 2022).

Barriers to SGLT2i on a patient level and system level were found in the literature. Specifically, in the United States, cost and insurance coverage disproportionately impacts the accessibility of these medications, especially those of lower economic status, a population that is already at high risk for HF (Khunti et al., 2022). For instance, copayment costs can range from under $10 to $600 monthly, depending on insurance (Khunti et al., 2022). Patient characteristics, such as being Black or Asian and being female, decreased the probability to receive a prescription for SGLT2i (Khunti et al., 2022). Additionally, patients with existing HF, CKD, prior hypoglycemia, and myocardial infarction were less likely to be prescribed a SGLT2i, despite compelling evidence of efficacy (Khunti et al., 2022). On a system level, Hussain et al. (2023) identified that few HF patients and eligible patients with risk factors for HF, such as ASCVD and T2DM, were not given SGLT2i. This implies a lack of standardized screening protocols which leads to a delay in evidenced-based patient care on a systems level (Hussain et al., 2023).

Primary Care Implementation Strategies of SGLT2i. Although there are many barriers to SGLT2i initiation in primary care, several implementation models have successfully narrowed the evidence-to-practice gap. Cross-disciplinary and education-based models have shown efficacy in SGLT2i utilization. For instance, a prospective quality improvement study, Heart Failure in Southern Sweden (HISS), implemented a cross-disciplinary, case-based educational intervention between PCPs and cardiologists that improved GDMT adherence in chronic stable HF patients in primary care (Milos Nymberg et al., 2026). Specifically, after the intervention, the utilization of SGLT2i and GDMT adherence increased from 20.8% at baseline to 37.7% post-intervention (Milos Nymberg et al., 2026). In another model, pharmacists led a quality improvement initiative in a primary care setting where SGLT2i use increased from 19.7% to 50.7% in eligible HF and CKD patients, demonstrating that SGLT2i utilization does not have to fall solely on the PCP and can be non-physician led (Cutrell et al., 2026). Cutrell et al. (2026) established that using this pharmacist-led method can prompt PCPs, such as NPs, to utilize their prescriptive authority and refer patients to this quality improvement initiative. Moreover, Khunti et al. (2022) writes that multidisciplinary education can be effective in increasing the utilization of SGLT2i in HF eligible patients, especially education that is interactive and case study based.

In addition to the cross-disciplinary and quality improvement models, there were systematic implementation approaches developed to ease providers into determining eligible HF patients through inclusion criteria. For instance, Norberg et al. (2024) developed a seven-step systematic implementation model that screened for HF patients eligible to take dapagliflozin using inclusion criteria from the DAPA-HF study which later prompted continual follow-up within a specialty outpatient setting. This approach resulted in 87% of medication adherence at 12 months in the remaining HF patients (Norberg et al., 2024). Moreover, in an Italian practice guide, Monzo et al. (2023) outlined patient selection criteria, SGLT2i initiation dose, and monitoring parameters to help providers confidently implement SGLT2i in their practice, which can be easily translated into a practice protocol for NPs.

Limitations, Gaps, and Future Recommendations

Although there is proven utility of SGLT2i initiation in primary care, the literature review contains limitations and gaps in knowledge regarding the research topic. One important limitation throughout the review of literature is the relationship between the 2022 ACC/AHA/HFSA Heart Failure guidelines and the research available in the reviewed studies. Proportionately, six out of the 14 articles reviewed were published pre-guidelines and during the same year that the guidelines were disseminated (Ahmad et al., 2021; Bazoukis et al., 2021; Böhm et al., 2020; Evans et al., 2022; Gager et al., 2021; Khunti et al., 2022). The other eight articles reviewed were post-guideline year (Bodea et al., 2026; Butler & Rich, 2024; Hussain et al., 2023; Milos Nymberg et al., 2026; Monzo et al., 2023; Norberg et al., 2024), with the most recent article published June 2026 (Cutrell et al., 2026). Specifically, Hussain et al. (2023) was the only study that identified utilization rates of SGLT2i in the United States from 2020, which is two years prior to the new guidelines indicating SGLT2i as part of GDMT in HF. Therefore, the impact of the guideline update on primary care remains grossly unmeasured. Since only four years have passed since the guideline update, there is insufficient evidence to evaluate the full dissemination of these recommendations. Therefore, more future research should focus on SGLT2i initiation rates in primary care in the United States after the 2022 guideline update.

One gap in knowledge is that there are no primary care intervention studies for the implementation of SGLT2i in HF patients completed in the United States. The implementation models synthesized were set in Sweden outpatient care settings (Milos Nymberg et al., 2026; Norberg et al., 2024). Because no study within this review examined interventions for the implementation of SGLT2i in the United States, there is a need for research within this geographical area. Cutrell et al. (2026) had a pharmacist-led model based in the United States, however, it was not PCP or NP-led. This collaborative model did involve the PCP; however, it was only through referral to the pharmacist (Cutrell et al., 2026). This demonstrates that future recommendations should focus on PCPs and/or NPs practicing in the United States.

Another gap is the lack of studies examining SGLT2i initiation in primary care for HFpEF specifically. Most implementation and utilization data revolve around HFrEF patient populations (Cutrell et al., 2026; Hussain et al., 2023; Norberg et al., 2024). This leaves the utilization of SGLT2i in those affected by HFpEF unstudied. Specifically, Hussain et al. (2023) examined the utilization rates of SGLT2i in HF patients within the Veteran Affairs (VA) system and found that older, HFpEF patients were the most missed groups in receiving SGLT2i. Therefore, the SGLT2i initiation in the HFpEF population needs to be further examined.

Additionally, the literature examined focused on the action of SGLT2i initiation and does not directly address medication adherence after initiation of SGLT2i of patients in primary care. The only implementation study that addresses this gap is by Norberg et al. (2024) where they found 87% medication adherence to SGLT2i after 12 months in a specialty outpatient setting, not in primary care. Therefore, more research needs to be conducted on medication adherence of SGLT2i in HF patients in primary care to fully understand the outcomes for HF patients taking these medications.

Lastly, the NP role in the initiation of SGLT2i for HF patients is a variable that has yet to be examined. Two studies advocated for PCPs’ role of SGLT2i initiation; however, it did not specify who within primary care, physicians, NPs, and physician associates. (Butler & Rich, 2024; Evans et al., 2022). Cutrell et al. (2026) demonstrated that a non-physician intervention is plausible through a pharmacist-led intervention, however, there has not been a study solely looking at the NP-led intervention, making it a necessary variable to research.

Summary of Review of Literature

In summary, the gathered literature directly answers the research question by confirming that SGLT2i initiation is associated with significant reductions in HF hospitalizations and CV death (Ahmad et al., 2021; Bodea et al., 2026; Gager et al., 2021). With the plethora of clinical evidence supporting these reductions, SGLT2i have great efficacy in improving patient outcomes by demonstrating benefits beyond glycemic control and confirming safety and consistency among all age groups. Though the evidence of efficacy exists, the real-world prescribing gap remains in primary care through SGLT2i underutilization and primary care’s central role in treating those with cardio-renal metabolic disease. Barriers to SGLT2i initiation in primary care include those on various levels, provider, patient, and system level barriers. To address these barriers, implementation strategies, such as cross-disciplinary and education-based models, pharmacist-led models, and systemic initiation protocols, have been studied to address the evidence-to-practice gap. Because the underutilization of SGLT2i was found to be low in primary care, NP-led initiation protocols are vital in reaching those at risk of HF and those with the disease already (Evans et al., 2022; Hussain et al., 2023).

The limitations and gaps of knowledge were also identified and supported. Time is a significant limitation to the review since more than 40% of the articles examined were prior to the groundbreaking guidelines being released. Gaps of knowledge include an absence of initiation studies in the United States, as implementation strategies were solely based in Sweden (Milos Nymberg et al., 2026; Norberg et al., 2024), and NP-led initiation studies, since implementation in the United States was only pharmacist-led (Cutrell et al., 2026). Additionally, the literature reviewed does not directly address the HFpEF population in SGLT2i implementation in primary care, instead it only addresses HFrEF populations, such as those studied by Hussain et al. (2023) and Böhm et al. (2022). Long-term medication adherence following primary care initiation is another gap that needs to be addressed. To date, only one study looked at long-term medication adherence in the context of a specialty outpatient clinic (Norberg et al., 2024). Lastly, while SGLT2i initiation is entirely feasible and appropriate within primary care (Evans et al., 2022; Milos Nymberg et al., 2026), the literature has yet to evaluate the NP role as a definitive variable influencing utilization and prescribing rates.

Consequently, future research should be investigated to address the gaps of SGLT2i in HF patients in primary care. For instance, research is needed is to evaluate the effectiveness of an NP-led SGLT2i initiation model specifically within primary care in the United States. Another opportunity is to target the HFpEF population in primary care, since it is the fastest growing HF type (Hussain et al., 2023; Khunti et al., 2022). Although the initiation stage is what was examined in the literature, longitudinal medication adherence studies following primary care initiation are essential to evaluate long-term, real-world efficacy of SGLT2i (Norberg et al., 2024). While there are limitations and gaps in this review, the existing literature provides substantial evidence to support immediate implementation, especially by NPs in primary care.

Related Social Determinates of Health

Social determinants of health (SDOH) impact HF risk, the progression of the disease, and the likelihood of receiving evidence-based treatments, such as SGLT2i (Brandt et al., 2023). In a prime example from the literature reviewed, Hussain et al. (2023) found that in the VA system, out of 105,799 patients eligible for SGLT2i, only 14.6% received the medication. This underutilization reflects the profound impact of SDOH on HF patients globally, ultimately creating barriers to access, affordability, and health literacy and preventing them from obtaining survival-prolonging therapies. Implementing evidence-based GDMT at the primary care level, rather than requiring a specialist referral, can significantly reduce barriers to healthcare access and quality for underserved populations with HF. SDOH influence HF patients’ ability to attain optimal CV health across these five domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context (Brandt et al., 2023).

Economic Stability

Access to SGLT2i remains a huge barrier to those affected by economic instability. Particularly, affordability of these medications is a factor that restricts access to those impacted by SDOH. Khunti et al. (2022) found that the median monthly average wholesale price of SGLT2i to be around $620 and average co-payment of these medications ranged from $10 to $600 monthly, likely coming from household incomes of at least $100,000 or greater. This demonstrates that economic situations, such as poverty, unemployment, and lack of insurance, can force HF patients to make a difficult decision between paying for critical medications out-of-pocket or foregoing provider-recommended therapies. To further emphasize the disparity of this domain, in the only study to provide utilization rates of SGLT2i in HFrEF, younger patients with higher socioeconomic status were more likely to receive this medication (Hussain et al., 2023). This leaves HF patients who are older populations more vulnerable to disease progression and those among lower economic status denied access to care. Utilization of a social worker or case manager, through referral from the PCP or within the healthcare system, can aid HF patients in attaining these medications to address this domain. Ultimately, PCPs and NPs can mitigate the costs of these medications by utilizing proactive medication assistance program referrals, manufacturer copay programs, and formulary awareness when prescribing SLGT2i to HF patients, thus promoting more equitable CV outcomes (Khunti et al., 2022).

Education Access and Quality

Reduced health literacy is an education access and quality SDOH that impacts both HF patients and healthcare provider interactions. Having poor health literacy influences many interconnected realms of a patient’s understanding of their chronic health condition. Specifically, reduced health literacy diminishes the capacity of a patient to comprehend their complex HF diagnosis, grasp the therapeutic rationale for SGLT2i treatment, and recognize the importance of strict medication adherence. When patients struggle to interpret complex clinical information given to them by their provider, poor self-management of symptoms, such as tracking daily weights or adjusting diuretics, can accelerate disease progression. Subsequently, a lower education level is associated with poorer HF self-management, higher hospitalization rates, and elevated mortality risk (Brandt et al., 2023).

NPs and nurses are skilled in providing patient education to address this domain. On the provider front, a lack of education of the benefits on SGLT2i for HF exists. Some PCPs are unaware of the cardio-renal benefits of SGLT2i and have fewer educational opportunities on SGLT2i than specialists (Khunti et al., 2022; Milder et al., 2021). Although the 2022 HF guidelines have been recently disseminated, there are still many opportunities for PCPs to increase their health literacy for evidence-based HF treatment. Milos Nymberg et al. (2026) demonstrated an attempt at narrowing the gap in health literacy for both patients and PCPs in their cross-disciplinary study involving educational conferences with cardiologists and PCPs, alongside highly individualized follow-up monitoring for HF patients. Intentional collaboration between primary care and specialists, like cardiologists, to promote better HF outcomes in underserved communities can help address this education access and quality domain.

Healthcare Access and Quality

Healthcare access and quality is a SDOH domain that directly affects those with HF. SGLT2i underutilization is compounded by low PCP utilization and specialist-dependent prescribing. Specifically, the young adult population and those in low-income areas have seen a decline in PCP utilization (Brandt et al., 2023). PCPs are essential in the delivery of preventative health services, facilitating access to specialty care, and referring families to community resources, like food stamps and population specific programs (Brandt et al., 2023). Lack of access to these vital healthcare services directly impacts SGLT2i underutilization. Moreover, deferring SGLT2i prescribing to specialists, such as endocrinologists or cardiologists, further widens the healthcare access and quality gap. Khunti et al. (2022) found that endocrinologists were among the most frequent prescribers of SGLT2i. Consequently, patients who lack specialist access, especially those in underserved communities, are systemically excluded from receiving this foundational component of GDMT. Therefore, primary care must spearhead SGLT2i initiation to reach those populations who lack access to specialized healthcare.

Neighborhood and Built Environment

Patients in disadvantaged neighborhoods and those experiencing housing instability are more likely to have HF and less likely to receive an SGLT2i. Those in disadvantaged neighborhoods often face proximity to fast-food environments and lack safe physical activity spaces to walk and exercise to prevent risk factors of HF, such as hypertension, obesity, and T2DM, all which SLGT2i address (Brandt et al., 2023). Physical activity is a cornerstone of HF self-management, and the absence of accessible sidewalks or green space can make those affected by HF less likely to implement this intervention (White-Williams et al., 2020). Locally, unhoused individuals, such as those in San Diego, frequently navigate mental health conditions, addiction, and substance use; over time, illicit drug use can cause HF. Those who experience housing instability have a greater propensity to develop HF, are less likely to seek care, and often face discrimination due to their situation. Lastly, limited transportation and pharmacy access within the built environment can prevent patients in underserved neighborhoods from picking up a prescription. This transportation barrier may explain why authors found that prescriptions for SGLT2i were written but never filled (Khunti et al., 2022).

Social and Community Context

Poor HF outcomes are associated with social isolation, a lack of caregiver support, and limited community health literacy (Brandt et al., 2023). Social support from a caregiver or family and community support through healthcare providers and advocates directly impacts medication adherence. Moreover, community and cultural influences on health decisions sway medication acceptance in diverse populations. For example, in the Latino population, faith and spirituality are highly connected to their health and overall well-being. Consequently, individuals within this community may hold varying beliefs on the utility of Western medications and lean towards more holistic and natural healing methods. This cultural belief directly shapes medication adherence to SGLT2i therapies. Acknowledging their beliefs and faith through a holistic and person-centered approach honors the social and community context while supporting SGLT2i adherence and overall HF self-management. PCPs, such as NPs, are ideally positioned to deliver a holistic, culturally competent approach to address this domain, ensuring these populations are not excluded from these mortality-reducing medications (Evans et al., 2022). Ideally, implementing a specialized HF team, consisting of a physician, NP, social worker or case manager, spiritual care provider, and nurse, to provide social and community support can ultimately promote better overall outcomes for HF patients.

Theoretical Framework

The Iowa Model of EBP is a theoretical framework that many healthcare organizations use to implement evidence-based research seamlessly into everyday practice (Collaborative et al., 2017). Originating in the early 1990s, this heuristic model was developed by nurses from University of Iowa hospital to successfully strategize in solving pertinent healthcare-related triggering issues and opportunities (Collaborative et al., 2017). The overarching objective of the Iowa Model is to bridge the evidence-to-practice gap by promoting excellence, reducing variations, empowering clinicians, and optimizing resources (Collaborative et al., 2017). These objectives align with those of NPs and offer a practical way to implement EBP change in the real world. The Iowa Model, as seen in Figure A3, is structured as a stepwise algorithm with seven actionable steps and three decision points that require evaluation and assessment within the process (Collaborative et al., 2017).

The topic of primary care initiation of SGLT2i in HF patients is directly applicable to the Iowa Model. Although SGLT2i have been proven to have great efficacy in promoting better CV outcomes, as supported by the 14 articles of this review and the 2022 ACC/AHA/HFSA HF guidelines, sustained effort is needed to bridge the prescribing gap in primary care (Hussain et al., 2023). This identified prescribing gap, alongside the evidence of SGLT2i efficacy in HF and other themes discussed in the literature review, constitutes as a knowledge-focused trigger and a problem-focused trigger. SGLT2i utilization in primary care is a high priority because the disease burden of HF is exceptionally high, affecting over 6 million Americans and significantly contributing to CV-related deaths and HF hospitalizations (Butler & Rich, 2024; CDC, 2025; Evans et al., 2022). The review of literature and the proposed intervention of an NP-led SGLT2i initiation protocol represents the Iowa Model’s evidence synthesis and practice change phases, respectively. This proposed intervention aims to foster and sustain practice change with the goal of promoting excellence in HF management.

Regarding the topic of primary care initiation of SGLT2i in HF patients, the stepwise algorithm is outlined accordingly. First, the triggers and opportunities consist of the knowledge-focused trigger and the problem-focused trigger, which stems from that fact that only 14.6% of eligible HF patients are receiving SGLT2i in primary care (Hussain et al., 2023). The second step is the research question utilized in the literature review: What impact does initiation of SGLT2 inhibitors have on heart failure patients in primary care? As discussed in the SDOH section of the paper, an interprofessional team, consisting of a cardiologist, NP, pharmacist, and social worker can be assembled to evaluate the evidence and design the intervention. Through the review of literature and thematic synthesis, the evidence has been assembled, appraised, and synthesized, fulfilling the fourth step of the framework. In the design and pilot phase of the Iowa Model, an NP-led SGLT2i initiation protocol can be implemented at the primary care level utilizing a combination of the implementation models presented in the thematic synthesis. Once the practice change is in place, it can be integrated and sustained by frequent monitoring and follow-up as outlined by Monzo et al. (2023). Lastly, findings from the intervention can be disseminated to the healthcare team and ideally replicated by other primary care practices nationwide. By executing this stepwise algorithm of the Iowa Model, primary care teams can effectively bridge the treatment gap and promote excellent outcomes for HF patients.

Advanced Practice Registered Nursing Role & Scope

The APRN, specifically the NP, is the best clinician to address the SGLT2i gap in primary care. The reviewed literature has established that SGLT2i are underutilized in primary care, where many HF patients are managed, and that structured non-physician initiation models are plausible and effective (Cutrell et al., 2026; Evans et al., 2022). Therefore, the NP is uniquely positioned to fill this gap, functioning at the intersection of clinical expertise, therapeutic patient relationships, and prescriptive authority. The NP role is defined by an advanced scope of practice that includes independent assessment, diagnosis, prescribing, and patient education (American Association of Nurse Practitioners [AANP], 2025). This scope of practice positions the NP as the PCP fully capable of leading SGLT2i initiation without requiring a specialist referral.

The scope of an NP can directly address the problem of SGLT2i underutilization in HF patients. The NP can develop a comprehensive care plan involving diagnosing the type of HF, interpreting echocardiographic findings, classifying EF, and managing HF medications. This foundation serves as a prerequisite to identifying eligible patients for SGLT2i initiation (Butler & Rich, 2024). In addition, a core competency of NPs is translating current evidence and clinical guidelines into an individualized, comprehensive care plan. NPs have the necessary training and legal authority to act upon the clinical directives outlined in the 2022 ACC/AHA/HFSA HF guidelines. Because the literature reviewed identified a gap in evidence-to-practice, the NP can address this gap in the real world (Evans et al., 2022). The prescriptive authority of an NP, which includes the ability to independently initiate, adjust, and discontinue SGLT2i therapy, is a central function that positions the NP, rather than a pharmacist, cardiologist or endocrinologist, to directly reach HF patients in primary care (Cutrell et al., 2026). Due to the progressive nature of HF, the NP’s long-term therapeutic relationship with patients can support the initiation of and adherence to SGLT2i, where side effects, monitoring and self-management can be addressed (Butler & Anderson, 2024; Monzo et al., 2023). Lastly, with a holistic perspective of caring for patients, NPs are trained to assess and address SDOH, ensuring that cost barriers, insurance issues, health literacy and cultural factors are fully addressed in a patient’s HF care (Evans et al., 2022; Khunti et al., 2022).

The American Association of Colleges of Nursing (AACN) outlines their ten Essential domains as a competency-based framework for the NP. The domains of Knowledge for Nursing Practice, Quality and Safety, and Interprofessional Partnerships are highly applicable to the proposed NP-led SGLT2i initiation intervention (AACN, 2026). In the first domain of Knowledge for Nursing Practice, the NP is required to synthesize evidence from multiple sources and translate that knowledge into individualized patient care decisions (AACN, 2026). This foundational competency justifies the proposed intervention through the evidence examined in the review of literature. Specifically, the NP applies the clinical knowledge base of HF pathophysiology, SGLT2i pharmacology, patient inclusion criteria, and dosing and monitoring parameters to safely and effectively initiate SGLT2i in primary care HF patients (Monzo et al., 2023). In the fifth domain, Quality and Safety, the NP uses quality improvement methods to evaluate and improve care processes and patient outcomes (AACN, 2026). As Hussain et al. (2023) summarized, SGLT2i underutilization is a quality and safety problem, since eligible HF patients are not receiving evidence-based GDMT with a demonstrated mortality benefit. Initiating the proposed intervention will directly measure quality outcomes so that the benefit can reach those who are eligible. Additionally, applying appropriate inclusion and exclusion criteria alongside close monitoring addresses the safety aspect of this competency. Lastly, the sixth domain, Interprofessional Partnerships, requires the NP to communicate, collaborate, and coordinate care effectively across profession disciplines (AACN, 2026). The SGLT2i initiation problem is one that cannot be resolved by the NP alone; rather, this requires intentional collaboration with cardiologists, pharmacists, and social workers to work in conjunction to produce the best possible outcomes for HF patients (Cutrell et al., 2026; Milos Nymberg et al., 2026). Within the literature, Milos Nymberg et al. (2026) demonstrated that cross-disciplinary collaboration between cardiologists and PCPs increased GDMT utilization, while Khunti et al. (2022) identified multidisciplinary approaches as an effective solution to the prescribing gap.

Having established the role and scope of an NP and the competencies needed for SGLT2i initiation in HF patients, the NP is the most appropriate and accessible clinician to lead a structured quality improvement protocol in the primary care setting. The following section presents a proposed intervention inspired by the cross-disciplinary education and initiation approach demonstrated in the HISS study (Milos Nymberg et al., 2026), which increased GDMT use from 20.8% to 37.7% in primary care patients with HF.

Proposed Intervention

Adapted from the HISS study by Milos Nymberg et al. (2026), the proposed intervention is a NP-led cross-disciplinary education and SGLT2i initiation quality improvement protocol in a primary care setting. This intervention will consist of three core components that occur in sequence: (1) an interprofessional education session to build primary care team knowledge of SGLT2i in HF, (2) systematic identification of eligible HF patients not currently receiving SGLT2i, and (3) NP-led initiation with individualized follow-up. By equipping the primary care team, particularly the providers, with the knowledge, tools, and collaborative structure, this intervention will directly address the evidence-to-practice gap identified in the review of literature, especially finding that only 14.6% of eligible HF patients in primary care receive SGLT2i (Hussain et al., 2023). Similar to the HISS study, the NP will serve as the lead implementer supported by a cardiologist and pharmacist who participates in a targeted education session and provides individualized treatment recommendations for complex cases (Milos Nymberg et al., 2026).

The setting of the intervention will be a primary care clinic where adult HF patients receive ongoing management. This intervention does not include any specialized equipment or infrastructure beyond the electronic health record (EHR) system and access to a cardiologist for the educational component, making this intervention broadly applicable to most primary care settings (Milos Nymberg et al., 2026). The target population will be adult patients ≥ 18 years of age with a confirmed HF diagnosis of any EF type (HFrEF, HFpEF) who are managed in primary care and not currently receiving SGLT2i therapy. Other inclusion criteria for this proposed intervention include an estimated glomerular filtration rate (eGFR) of ≥ 20 mL/min/1.73m2 adapted from the prescribing guidance of Monzo et al. (2023) and the landmark SGLT2i HF trials (Butler & Rich, 2024). Patient exclusion criteria are: eGFR of 20 mL/min/1.73m2, history of recurrent DKA, type 1 diabetes mellitus, active urogenital infection, and hospice or comfort-care status. This inclusive approach reflects the 2022 HF guideline recommendations of SGLT2i across all HF types (Butler & Rich, 2024).

The three core components of the quality improvement protocol will be implemented in sequence. This includes a cross-disciplinary education session, systematic patient identification and individualized treatment recommendations, and NP-led initiation with follow-up monitoring. Organized by the primary care clinic, the education session component will be an educational conference with a cardiologist and/or pharmacist and the primary care team. The conference will cover current SGLT2i evidence, 2022 ACC/AHA/HFSA HF guideline recommendations, patient eligibility criteria, prescribing protocols, and common side effect management, highly focusing on case study discussions as the most effect format for PCP learning (Khunti et al., 2022; Milos Nymberg et al., 2026). Although the exact delivery of education material was not explicitly stated in the HISS study, teaching modalities of visual information graphics, small-group learning, and interactive experiences can be utilized to enhance the quality of education. The duration of the conference can vary depending on the knowledge deficit of the team and HF patient population need but can realistically be completed within a day and can potentially count as education credits as further incentive.

Afterwards, to address the second component, the NP will conduct a systematic review of the clinic’s HF patient panel using EHR system to identify eligible patients not yet receiving SGLT2i (Milos Nymberg et al., 2026). This can be done seamlessly if the EHR system can filter patients with International Classification of Diseases (ICD) codes for HF, such as I50, I11.0, I42 (excluding I42.1, I42.2) and I43, used by Milos Nymberg et al. (2026). For each identified patient, individualized treatment recommendations are developed with special considerations for HF type, eGFR, comorbidities, and concomitant medications (Milos Nymberg et al., 2026). For troubleshooting complex cases and additional support, collaboration with the cardiologist from the education session should be easily accessible and expected for safe and comprehensive care. The last component will involve the NP to initiate SGLT2 therapy during a scheduled primary care visit. SGLT2i therapy will include dapagliflozin 10 mg or empagliflozin 10 mg daily, depending on what is appropriate for each individual patient. The visit will incorporate patient education on benefits of the medication, expected side effects, and monitoring, while any patient questions or concerns will be addressed. Follow-up will then be scheduled at four to six weeks post-initiation to assess tolerability and labs, with ongoing monitoring at three and six months (Monzo et al., 2023).

Outcomes, Timelines, and Evaluation

This proposed intervention will have several measurable outcomes that are health promoting and aligned with the Iowa Model. Primary outcomes include the SGLT2i initiation rate and GDMT adherence rate. The SGLT2i initiation rate will be the proportion of eligible HF patients identified who receive and fill an SGLT2i prescription with the target of ≥ 50% initiation rate, consistent with the HISS study’s improvement in GDMT increase of 20.8% to 37.7% (Milos Nymberg et al., 2026). Another primary outcome will look at GDMT adherence by calculating the proportion of initiated patients remaining on SGLT2i at six months without discontinuation with a target of ≥ 80% consistent with Norberg et al. (2024) achieving 87% adherence at 12 months. Secondary outcomes can be measured looking at the patient’s quality of life and HF-related hospitalizations. To assess the HF patient’s quality of life, a baseline KCCQ-12 score will be measured at initial visit and at the six-month follow-up (Bodea et al., 2026) and a target of ≥ 5-point improvement will be considered as the minimally important difference. Another secondary outcome that would be relevant to examine and compare is HF hospitalizations. Examining the number of HF hospitalizations or urgent care visits six months prior to initiation and comparing it to the number of HF hospitalizations or urgent care post SGLT2i initiation will be compared. Due to SGLT2i efficacy in the landmark HF trials, a 23-32% reduction of HF hospitalizations is expected (Butler & Rich, 2024). Lastly, process outcomes are measured through provider knowledge improvement and renal safety monitoring. A survey ranking the knowledge and confidence of SGLT2i prescribing for HF will be given to the primary care team before and after the education session to determine the change in clinical knowledge and confidence ratings of evidence-based HF treatment. Renal safety monitoring is a process outcome that must be measured. Rate of eGFR change from baseline to six months post-initiation will be monitored since an attenuated decline is expected per the trial data; an acute GFR decline of greater than 30% within four to six weeks will trigger a reassessment for safety

(Bodea et al., 2026; Böhm et al., 2020; Jiron Vindas et al., 2026; Monzo et al., 2023).

The timeline for the intervention will incorporate the measured outcomes within the first 12 months. In the first four weeks of protocol, a team is formed and education is disseminated through the educational conference. Also, the baseline knowledge and confidence survey will be given at this time, patient education materials will be developed in several languages to be given to the HF patients during their initial visit, and an identification process will be established to find eligible HF patients through the EHR. In the first two months, inclusion and exclusion criteria are used to further narrow eligible and ineligible patients, and individualized treatment plans are developed with the support of a cardiologist. During a patient visit, the SGLT2i will be initiated and the outcomes measure on the KCCQ-12 will be given to patients, and the post-survey of knowledge and confidence will be given to the primary care team. In months two and three, early follow-up post-initiation will take place ensuring that adverse effects are managed (Monzo et al., 2023). This time frame will be an opportunity to address any SDOH, for example, if a social worker needs to be involved, and a brief team check-in to review initiation rates, early barriers, and any protocol adjustments needed. Follow-up will then occur during the three-month visit, assessing eGFR, electrolytes, blood pressure, and symptom review, while later, at the six-month visit, repeat labs, the KCCQ-12, HF hospitalization review can be measured. At the end of this period, the outcome data will be compiled, and the interprofessional team will debrief to present findings and reassess protocol effectiveness. The collaboration between the NP, cardiologist, pharmacist, and others in the primary care team during the six-month debrief will determine whether the protocol is ready for integration into standard practice as modeled in the HISS study (Milos Nymberg et al., 2026). If the outcome measures are met after all the six-month visits are complete, then SGLT2i screening can be integrated into a routine HF visit workflow. With deliberate evaluation and assessment, this proposed intervention can then be expanded to other PCPs within the clinic and a 12-month reassessment of medication adherence for patients can be completed.

Evaluation follows the Iowa Model’s outcome evaluation step in assessing whether the practice change achieved the desired results before determining whether the intervention is sustained, replicable, or expanded (Collaborative et al., 2017). Ultimately, positive outcomes will direct the primary care team to integrate and sustain the practice change with the goal of disseminating evidence-based results. If there are barriers along the way and opportunities to refine protocol, constant re-evaluation can occur using the Iowa Model to ensure an iterative, evidence-based approach (Collaborative et al., 2017).

Conclusion

Heart failure is one of the most prevalent and burdensome chronic health conditions in the United States affecting over 6 million adults and carrying significant risk of morbidity, mortality, and repeated hospitalization (Butler & Rich, 2024; CDC, 2025). Even with the availability of SGLT2i, a survival-prolonging class of medications with demonstrated, guideline-supported efficacy across the spectrum of HF types, initiation of these medications remains critically underutilized in primary care (Hussain et al., 2023). This paper has systematically examined this evidence-to-practice gap and proposed intervention of an NP-led quality improvement protocol grounded in current evidence, theory, and interprofessional collaboration. In the literature review, themes of clinical evidence efficacy, the prescribing gap, barriers to initiation, and implementation strategies were found, which demonstrated that HF outcomes were not affected by lack of effective therapy, but lack of initiation (Bodea et al., 2026; Hussain et al., 2023). The SDOH analysis revealed that the prescribing gap is not uniformly distributed, as factors of economic instability, limited healthcare access, low health literacy, and neighborhood disadvantage, disproportionately limit HF patients’ access to SGLT2i in primary care (Evans et al., 2022; Khunti et al., 2022). The Iowa Model of EBP provided the theoretical framework used to identify SGLT2i underutilization as a knowledge-focused and problem trigger for action (Collaborative et al., 2017).

Primary care NPs, with prescriptive authority, advanced clinical competencies across the AACN Essentials domains, and holistic patient-centered approach, are best positioned to lead SGLT2i initiation in the proposed intervention (AACN, 2026; Cutrell et al., 2026; Evans et al., 2022). A cross-disciplinary education and NP-led SGLT2i initiation quality improvement protocol was adapted from the HISS study so that initiation rates, medication adherence, and quality of life measures can determined and in a primary care setting (Milos Nymberg et al., 2026). If sustained and successful, this intervention has the potential to improve patient outcomes by reducing the healthcare burden and mortality in primary care (Bodea et al., 2026). In practice, NPs and PCPs should be proactively screening their HF patients for SGLT2i eligibility so that therapy can be initiated and continuing education for practicing providers should be up to date due to the rapid evolution of HF guidelines since 2022. Finally, SGLT2i have proven to change the trajectory of HF and NPs are not simply capable of leading this practice change, they are positioned and professionally obligated to do so.

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Appendix

Operational Definitions

Table A1

ACC/AHA Stages of Heart Failure

Note. From “Heart Failure and Ejection Fraction,” by M. Golla, S. Hajouli, and D. Ludhwani, 2024, StatPearls, (https://www.ncbi.nlm.nih.gov/books/NBK553115/).

Table A2

NYHA Classification of HF

Note. From “Heart Failure and Ejection Fraction,” by M. Golla, S. Hajouli, and D. Ludhwani, 2024, StatPearls, (https://www.ncbi.nlm.nih.gov/books/NBK553115/).

Figure A1

ACC/AHA Class (Strength) of Recommendation

Note. From “Table 2 of 2022 AHA/ACC/HFSA Heart Failure Guidelines,” Heidenreich et al., 2022, Circulation, (https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063).

Review of Literature

Table A3 Link to Search

Figure A2 PRISMA Diagram

Table A4 Review of Literature and Evidence Table

Theoretical Framework

Figure A3 Iowa Model – Revised