Identifying Barriers to Hypertension Care: Implications for Quality Improvement Initiatives

Abstract

The role of clinical inertia in the treatment of patients with hypertension was assessed by evaluating health care providers' knowledge, attitudes, and clinical practices regarding hypertension management. A cross-sectional survey was conducted at the Forsyth Medical Group in North Carolina. Participants were physicians (N = 18, 10 sites) and support staff (N = 20, 12 sites), who were surveyed in 2006. Physician and support staff questionnaires consisted of 29 and 15 items, respectively, and were administered by trained interviewers. Though most physicians (94%) cited familiarity with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) guidelines and affirmed that hypertension management guidelines are relevant to their patients, no physicians interviewed routinely document patient hypertension management plans. Although 1 in 3 physicians cited the inability to devote enough time to patients for the discussion of hypertension management, physicians predominantly cited patient- and support-staff- related factors as most important to patients not attaining blood pressure (BP) goal. Patient lifestyle modification (89%), education (67%), and medication compliance (56%) were cited as the most important reasons for uncontrolled BP. Only one-third of physicians believe that clinical staff always obtain accurate BP measurements, and 61% believe that resistant hypertension is a reflection of inaccurate BP measurement. Many support staff claimed to be rushed when measuring patient BP, and 65% recommended BP competency training. Contradictions were evident between provider knowledge of hypertension management standards and how this knowledge is applied in clinical practice. Standardized collection of BP is critical to measuring clinical improvement in hypertension. Results are being utilized to develop clinical improvement initiatives including staff education and competency training.

Is blood pressure control to less than 140/less than 90 mmHg in 50% of all hypertensive patients as good as we can do in the USA: or is this as good as it gets?

“…When evaluating quintiles of therapeutic inertia, we observed that the quintile with the lowest therapeutic inertia achieved 75% control rates during the following year, whereas patients in the quintile with the highest therapeutic inertia achieved only 8% control rates [25]. Although patient nonadherence is cited by physicians as a reason not to intensify therapy [27], BP often declines when therapy is intensified, even in patients perceived to be less adherent [26 ].…”

“…Physicians are not confident of the validity of BP values recorded by their office staff [28]. This uncertainty, in turn, reduces the likelihood that action will be taken in response to an elevated reading [27,28]. Thus, the real and perceived inaccuracy in measuring office BP, combined with the substantial likelihood of a white coat or office effect on BP, reduces the likelihood that providers will intensify treatment in response to an elevated value.…”

“…The pace of progress realized during this limited period will be difficult to replicate going forward, yet there are clearly opportunities for continued improvement. Specifically, the majority of uncontrolled hypertensives remain untreated, that is, 27.5% of all hypertensives and 55% of uncontrolled patients (Fig. 2).…”

Quality Improvement Initiatives Improve Hypertension Care Among Veterans

“…It has been shown that encouragement by physicians can help to enhance patient compliance. 8,26,27 Patients perceive their physicians as a "very/extremely" useful source of information, 28 and thus a third component of our intervention focused on improving patient knowledge. 29 The last component of our multifaceted intervention addressed the educational needs and time demands of our nursing staff.…”

“…The belief that inaccurate BP measurements are obtained by clinical staff is common among physicians; meanwhile, support staff report being rushed while measuring BPs, and many request BP competence training. 26 We constructed our intervention to address both of these needs.…”