Developing an Actionable Taxonomy of Persistent Hypertension Using Electronic Health Records

Abstract

BACKGROUND: The digital transformation of medical data presents opportunities for novel approaches to manage patients with persistent hypertension. We sought to develop an actionable taxonomy of patients with persistent hypertension (defined as 5 or more consecutive measurements of blood pressure ≥160/100 mmHg over time) based on data from the electronic health records. METHODS: This qualitative study was a content analysis of clinician notes in the electronic health records of patients in the Yale New Haven Health System. Eligible patients were 18 to 85 years and had blood pressure ≥160/100 mmHg at 5 or more consecutive outpatient visits between January 1, 2013 and October 31, 2018. A total of 1664 patients met criteria, of which 200 records were randomly selected for chart review. Through a systematic, inductive approach, we developed a rubric to abstract data from the electronic health records and then analyzed the abstracted data qualitatively using conventional content analysis until saturation was reached. RESULTS: We reached saturation with 115 patients, who had a mean age of 68.1 (SD, 11.6) years; 54.8% were female; 52.2%, 30.4%, and 13.9% were White, Black, and Hispanic patients. We identified 3 content domains related to persistence of hypertension: (1) non-intensification of pharmacological treatment, defined as absence of antihypertensive treatment intensification in response to persistent severely elevated blood pressure; (2) non-implementation of prescribed treatment, defined as a documentation of provider recommending a specified treatment plan to address hypertension but treatment plan not being implemented; and (3) non-response to prescribed treatment, defined as clinician-acknowledged persistent hypertension despite documented effort to escalate existing pharmacologic agents and addition of additional pharmacologic agents with presumption of adherence. CONCLUSIONS: This study presents a novel actionable taxonomy for classifying patients with persistent hypertension by their contributing causes based on electronic health record data. These categories can be automated and linked to specific types of actions to address them.

Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records

“…We have previously detailed various mechanisms through which patients experience persistent hypertension, such as the lack of intensification in pharmacological treatment, failure to implement prescribed therapies, and non-response to treatment. 10 Building on this, the current study specifically illuminates the mechanisms behind clinicians' failure to treat ambulatory patients with severely elevated BP effectively and explores the reasons for these shortcomings. To our knowledge, this is the first study to develop a taxonomy for categorizing instances of suboptimal clinician adherence to guidelines in managing patients with markedly elevated BP using real-world data.…”

“…Using a previously published inductive, systematic approach, [9][10][11][12][13] we conducted a thematic analysis of EHR data to generate a real-world taxonomy of suboptimal clinician guideline adherence scenarios in managing severe hypertension. Then, we postulated plausible reasons/influencing factors/root causes for each taxonomized scenario based on contexts adopted from a previously published metareview of 25 systematic reviews on the factors influencing the implementation of clinical practice guidelines.…”

Barriers to Optimal Clinician Guideline Adherence in Management of Markedly Elevated Blood Pressure

“…Using a previously published inductive, systematic approach, [10][11][12][13][14] we conducted a thematic analysis of EHR data to generate a pragmatic taxonomy of suboptimal clinician guideline adherence scenarios in managing severe hypertension.…”

“…Such a pragmatic framework is poised to inform targeted interventions, thus enhancing adherence and patient outcomes.Our study advances the existing body of literature in several ways. We have previously detailed various mechanisms through which patients experience persistent hypertension, such as the lack of intensification in pharmacological treatment, failure to implement prescribed therapies, and nonresponse to treatment 11. Building on this, the current study specifically illuminates the mechanisms behind clinicians' failure to treat ambulatory patients with severely elevated BP effectively and explores the reasons for these shortcomings.…”