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Abstract

  1. Top of page
  2. Abstract
  3. PATIENT-RELATED BARRIERS TO BP CONTROL
  4. PHYSICIAN-RELATED BARRIERS TO BP CONTROL
  5. REASONS FOR CLINICAL INERTIA
  6. Disclosure:
  7. Suggested Reading

There is an obvious gap in the translation of clinical trial evidence into practice with regards to optimal hypertension control. The three major categories of barriers to BP control are patient-related, physician-related, and medical environment/health care system factors. Patient-related barriers include poor medication adherence, beliefs about hypertension and its treatment, depression, health literacy, comorbidity, and patient motivation. The most pertinent is medication adherence, given its centrality to the other factors. The most salient physician-related barrier is clinical inertia—defined, as the failure of health care providers to initiate or intensify drug therapy in a patient with uncontrolled BP. The major reasons for clinical inertia are: 1) overestimation of the amount of care that physicians provide; 2) lack of training on how to attain target BP levels; and 3) clinicians' use of soft reasons to avoid treatment intensification by adopting a “wait until next visit” approach in response to patients' excuses.

Despite the proven efficacy of drug therapy from clinical trials in improving hypertension-related morbidity and mortality, suboptimal blood pressure (BP) control remains a pervasive problem. There is an obvious gap in the translation of clinical trial evidence into practice with regard to optimal BP control, and a comprehensive understanding of the barriers to BP control is needed to address this issue. Using a conceptual model to describe the complex factors that affect BP control, barriers to optimal hypertension control can be categorized into three main domains: patient-related barriers, physician-related barriers, and factors related to the medical environment or health care system. Although factors related to the medical environment and health care system (lack of access to care, cost of medications, low socioeconomic status) account for some variance of uncontrolled hypertension, they are probably less salient when it comes to management of patients who are insured and have a regular source of care. According to National Health and Nutrition Examination Survey (NHANES) data, most cases of uncontrolled hypertension occur in patients who have health insurance and a usual source of care. Furthermore, patients with treated but uncontrolled hypertension visited a physician a mean of >6 times in the previous year. Thus, undiagnosed hypertension and treated but uncontrolled hypertension occur largely under the watchful eyes of the health care system. This makes patient-and physician-related barriers assume an even more important role than the health care system or lack of access to care.

PATIENT-RELATED BARRIERS TO BP CONTROL

  1. Top of page
  2. Abstract
  3. PATIENT-RELATED BARRIERS TO BP CONTROL
  4. PHYSICIAN-RELATED BARRIERS TO BP CONTROL
  5. REASONS FOR CLINICAL INERTIA
  6. Disclosure:
  7. Suggested Reading

Poor medication adherence, patients' beliefs about hypertension and its treatment, depression and other cognitive dysfunction, low health literacy, comorbidities, patient motivation, coping, and lack of social support are all patient-related barriers to controlled BP. The most pertinent of these factors is poor medication adherence, given its central role and its relationship to the other factors. Poor medication adherence among hypertensive patients ranges from 43% to 88% depending on the measure of adherence chosen. It is purported that within the first year of treatment, 16% to 50% of patients discontinue their antihypertensive medications. In a study of newly diagnosed hypertension, adherence rates ranged from 81% in the first month to 73% at 3 months and finally dropped to 56% at 18 months. Good adherence is generally assumed to be associated with improved BP control and reduced complications.

More recently, poor medication adherence has been linked to increased mortality. An important determinant of medication adherence that is often ignored in the literature is patients' beliefs about their illness and prescribed medications. Patients often have cognitive representations of their illness and its treatment (especially as it relates to the necessity of medications, fear of complications, and concerns about side effects) that may not be congruent with the traditional biomedical paradigm. They make rational decisions about benefits and risks of medications before deciding whether to comply with recommended treatment. Several investigators have linked patients' beliefs to poor medication adherence.

PHYSICIAN-RELATED BARRIERS TO BP CONTROL

  1. Top of page
  2. Abstract
  3. PATIENT-RELATED BARRIERS TO BP CONTROL
  4. PHYSICIAN-RELATED BARRIERS TO BP CONTROL
  5. REASONS FOR CLINICAL INERTIA
  6. Disclosure:
  7. Suggested Reading

Examples of physician-related barriers to controlled BP are lack of intensity of drug therapy (also known as clinical inertia), communication style, and awareness and knowledge of treatment guidelines. Perhaps the most pertinent of these factors is clinical inertia, which is defined as the failure of health care providers to initiate or intensify drug therapy appropriately in a patient with uncontrolled BP. Surveys indicate that physicians do not believe in initiating or intensifying drug therapy when BP is above guideline-recommended thresholds. For instance, in a national survey of 379 primary care physicians, 39% would not initiate drug therapy unless the diastolic BP was at least 95 mm Hg, and 52% would not start therapy unless the systolic BP was at least 160 mm Hg, thus indicating higher thresholds than recommended by guidelines. Similarly, 33% of physicians in the same survey would not intensify therapy in a patient with a persistently elevated BP level of 158/88 mm Hg, nor would 25% for a patient with a BP level of 138/94 mm Hg. Studies that examined clinicians' actual practices in managing hypertensive patients also reported high levels of clinical inertia. For instance, in one study of 270 patient visits among patients with persistently elevated BP for longer than 6 months, treatment intensification occurred at only 37% of visits. Similarly, Berlowitz and colleagues examined the care of 800 hypertensive men at Veterans Administration sites over a 2-year period. Forty percent of the patients had a BP level >160/90 mm Hg despite an average of >6 clinic visits per year, and they had a total of 6391 hypertension-related visits. Drug therapy was intensified at only 6.7% of these visits in the time period studied. Therapy was increased at 22% of visits with systolic BP levels >165 mm Hg and normal diastolic BP and at 25% of visits with BP values >155/90 mm Hg. Thus, for about three-quarters of visits at which elevated BP levels were recorded, physicians did not increase medications. Finally, in a study of 3347 hypertension-related visits among 681 HMO patients, therapy was intensified at only 12% of the visits for the 1-year study period despite the fact that 33% of patients had BP levels that were not at the target value for any visit.

REASONS FOR CLINICAL INERTIA

  1. Top of page
  2. Abstract
  3. PATIENT-RELATED BARRIERS TO BP CONTROL
  4. PHYSICIAN-RELATED BARRIERS TO BP CONTROL
  5. REASONS FOR CLINICAL INERTIA
  6. Disclosure:
  7. Suggested Reading

Reasons for lack of aggressiveness in initiating or intensifying drug therapy on the part of primary care physicians are not clear. However, 3 major reasons have been generally implicated as possible culprits. First is the overestimation of the amount of care that physicians actually provide believing that they are more aggressive than they actually are. Second is the lack of training on how to attain target BP levels, especially with inadequate structural support for such care, most important of which is electronic medical records. A recent study indicated lower rates of clinical inertia in recent graduates from residency programs compared with older physicians. The final reason is clinicians' use of soft reasons to avoid intensification of therapy by adopting a “wait until next visit” approach in response to patients' excuses of missing their doses, being under too much stress, and rushing into the clinic. Others reasons include financial pressures that could limit time for patient care, concern about cost and medication side effects, lack of familiarity with treatment guidelines, and a reflection of patients' lack of enthusiasm for management of asymptomatic problems such as hypertension.

Given the complex nature of potential interventions targeted at optimal hypertension control, a comprehensive approach focused on all the domains of the conceptual model outlined above is necessary. The recent pay-for-performance approach adopted by Medicare may not be comprehensive enough to address these issues.

Disclosure:

  1. Top of page
  2. Abstract
  3. PATIENT-RELATED BARRIERS TO BP CONTROL
  4. PHYSICIAN-RELATED BARRIERS TO BP CONTROL
  5. REASONS FOR CLINICAL INERTIA
  6. Disclosure:
  7. Suggested Reading

Dr. Ogedegbe is supported by funding from grant R01HL078566 from the National Heart, Lung, and Blood Institute.

Suggested Reading

  1. Top of page
  2. Abstract
  3. PATIENT-RELATED BARRIERS TO BP CONTROL
  4. PHYSICIAN-RELATED BARRIERS TO BP CONTROL
  5. REASONS FOR CLINICAL INERTIA
  6. Disclosure:
  7. Suggested Reading