General Practice Organisational Models and Heart Failure Medication Adherence: Multi-Level Evidence from A Regional Cohort in Emilia-Romagna, Italy

Background: Medication adherence is essential for improving heart failure outcomes yet remains suboptimal. Organisational models in general practice-such as group practices and Community Health Centres-have long been promoted as a means to strengthen primary care and are currently undergoing national reform. However, their impact on adherence remains unclear. This study investigated whether general practice organisational arrangements were associated with adherence to therapies recommended by clinical guidelines for heart failure. Methods: We conducted a retrospective cohort study using linked administrative data from the Romagna Local Health Authority (Northern Italy), encompassing all adults discharged with an incident diagnosis of heart failure between January 2020 and March 2023. The primary outcome was adherence to angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or β-blockers over one year, based on pharmacy claims. The exposure was the general practice organisational model: group practice within a Community Health Centre, group practice outside a Community Health Centre, or solo/networked practice. We used multilevel logistic regression to estimate adjusted associations, accounting for patient- and context-level confounders, with additional stratified analyses by health district. Results: No systematic association emerged between general practice organisational models and adherence in the overall cohort of 3,304 patients with heart failure. However, in one district (Rubicone), group practices were associated with higher adherence (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers: odds ratio = 3.00, 95% confidence interval 1.48-6.09, P = 0.002; β-blockers: odds ratio = 1.81, 95% confidence interval 0.98-3.37, P = 0.06). Residual variation between general practitioners was modest but not negligible. Conclusion: Organisational arrangements alone may be insufficient to improve adherence in heart failure care. Their effectiveness likely depends on how they are implemented and supported at the local level, through clinical leadership, specialist involvement, and integration across care settings. As new national reforms promote broader structural change, our findings underscore the importance of local facilitators and context-sensitive implementation. These insights are particularly relevant for understanding the operational strengths and weaknesses of legacy models that are now being phased out.