Obstacles Abound for Treating Severe BP: Some Clues for Care Lie in EHRs

Patients with severe hypertension face many barriers to receiving guideline-directed medication, and a qualitative study of electronic health records (EHRs), published online this week in JAMA Network Open, sheds some light on what’s driving the suboptimal adherence.

Clinicians and patients influence prescribing patterns, researchers found, as does the medical complexity of the scenario.

Lead author Yuan Lu, ScD (Yale School of Medicine, New Haven, CT), told TCTMD their “study was motivated by the critical public health issue of hypertension,” with a particular focus on clinician behavior.

One in eight patients with hypertension have severely elevated BP levels, a group for which US and European guidelines advise prompt evaluation, drug therapy, and monitoring, with dose adjustments as necessary. But many fail to receive this quality of care, Lu pointed out. “The big discrepancy between the guidelines and the practice, especially among patients with extreme blood pressure levels that cause high risk of complications, is what [prompted us] to investigate the underlying reasons for this gap.”

For Lu, the “chief finding” from their work is that the issue isn’t simple.

Michel Burnier, MD (University of Lausanne, Saint-Legier, Switzerland), in an editorial, praises the study for taking an open perspective when looking at underuse of medical therapy in hypertension.

“In recent years, great attention has been paid to patients’ nonadherence to prescribed drugs as an important determinant of uncontrolled BP,” he writes. “Unfortunately, less attention has been paid to the physicians’ poor adherence to the implementation of hypertension practice guidelines or therapeutic inertia, which may also have a substantial impact on the rate of hypertension control.”

The new framework, says Burnier, points to clinician inertia as a contributor that needs to be tackled.

Clinicians, Patients, Complexity

Using EHR data, Lu and colleagues identified 57,418 patients ages 18 to 85 years in the Yale New Haven Health System who had at least two consecutive visits with BP readings of 160/100 mm Hg or higher between the years 2013 and 2021. Among these patients, 20,654—slightly more than a third—did not receive a prescription within 90 days of their second BP measurement.

The researchers then created a model using a smaller sample of randomly selected patients that generated a taxonomy envisioning various scenarios that might explain the suboptimal care.

Reasons for not initiating or intensifying treatment fell under three categories related to:

• Clinician intention, capability, or scope (did not address or diffusion of responsibility)
• Patient behavior (nonadherence or preference)
• Clinical complexity (diagnostic uncertainty, maintenance of current intervention, or competing medical priorities)

The resulting “pragmatic framework is poised to inform targeted interventions, thus enhancing adherence and patient outcomes,” the investigators write.

A one-size-fits-all approach will not solve the issue. Yuan Lu

Importantly, said Lu, “a one-size-fits-all approach will not solve the issue.” Instead, solutions must be targeted at the specific obstacles that stand in the way, she stressed.

For clinicians in particular, possible barriers to guideline-directed care “include unclear institutional roles, insufficient consultation time, excessive workload, and infrastructure limitations. Factors such as clinician autonomy, authority, or role misperceptions can also play a part, alongside unclear guidelines,” the researchers say, suggesting that healthcare systems can make a difference by integrating decision support tools, like automated alerts, into EHR systems and by offering better collaborative tools for care teams.

“Addressing health professional–level factors involves fostering a willingness to embrace new practices, educating about guidelines, and reinforcing personal accountability,” they add.

According to Lu et al, other remedies can address the guidelines themselves, such as by simplifying how they are communicated and allowing more flexibility in how the recommendations can be tailored to local needs.

Burnier agrees that some of the clinician-related aspects are legitimate, such as when the hypertension diagnosis wasn’t confirmed or there was another serious condition that took center stage. But the bigger issue appears to be physician clinical inertia, particularly the “total absence of any intervention” between the first and second visits, he asserts.

Lu said that, as a follow-up project, she and her colleagues hope to do a mixed methods study that involves interviews with patients and healthcare professionals, not just EHR data. They’re also interested in looking at the utility of a “command center” approach to hypertension in which personnel can monitor the stream of patients that go through the healthcare system and help triage those who merit follow-up to the right provider.