Clinical awareness of adherence to hypertension guidelines

Duke University, Durham, North Carolina, United States
The American Journal of Medicine (Impact Factor: 5). 11/2004; 117(10):747-54. DOI: 10.1016/j.amjmed.2004.03.035
Source: PubMed


Little is known about how well clinicians are aware of their own adherence to clinical guidelines, an important indicator of quality. We compared clinicians' beliefs about their adherence to hypertension guidelines with data on their actual performance.
We surveyed 139 primary care clinicians at three Veterans Affairs medical centers, asking them to assess their own adherence to hypertension guidelines. We then extracted data from the centers' clinical databases on guideline-concordant medication use and blood pressure control for patients cared for by these providers during a 6-month period. Data were collected for patients with hypertension and diabetes, hypertension and coronary disease, or hypertension with neither of these comorbid conditions.
Eighty-six clinicians (62%) completed the survey. Each clinician saw a median of 94 patients with hypertension (mean age, 65 years). Patients were treated with an average of 1.6 antihypertensive medications. Overall, clinicians overestimated the proportion of their patients who were prescribed guideline-concordant medications (75% perceived vs. 67% actual, P <0.001) and who had blood pressure levels <140/90 mm Hg on their last visit (68% perceived vs. 43% actual, P <0.001). Among individual clinicians, there were no significant correlations between perceived and actual guideline adherence (r = 0.18 for medications, r = 0.14 for blood pressure control; P > or =0.10 for both). Clinicians with relatively low actual guideline performance were most likely to overestimate their adherence to medication recommendations and blood pressure targets.
Clinicians appear to overestimate their adherence to hypertension guidelines, particularly with regards to the proportion of their patients with controlled blood pressure. This limited awareness may represent a barrier to successful implementation of guidelines, and could be addressed through the use of provider profiles and point-of-service feedback to clinicians.

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    • "Other studies have found that one reason physicians say they theoretically would not intensify treatment [10], [11], or actually do not intensify it in their own practice [10], [12], [13], is satisfaction with BP values close to the therapeutic goal. In reality, physicians usually overestimate the degree of BP control in their patients [14]–[16]. Other studies have reported that BP levels at the office visit predict antihypertensive medication change [9], [17]–[19]. "
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    ABSTRACT: We examined physician perception of blood pressure control and treatment behavior in patients with previous cardiovascular disease and uncontrolled hypertension as defined by European Guidelines. A cross-sectional study was conducted in which 321 primary care physicians throughout Spain consecutively studied 1,614 patients aged ≥18 years who had been diagnosed and treated for hypertension (blood pressure ≥140/90 mmHg), and had suffered a documented cardiovascular event. The mean value of three blood pressure measurements taken using standardized procedures was used for statistical analysis. Mean blood pressure was 143.4/84.9 mmHg, and only 11.6% of these cardiovascular patients were controlled according to 2007 European Guidelines for Hypertension Management target of <130/80 mmHg. In 702 (49.2%) of the 1426 uncontrolled patients, antihypertensive medication was not changed, and in 480 (68.4%) of these cases this was due to the physicians judgment that blood pressure was adequately controlled. In 320 (66.7%) of the latter patients, blood pressure was 130-139/80-89 mmHg. Blood pressure level was the main factor associated (inversely) with no change in treatment due to physician perception of adequate control, irrespective of sociodemographic and clinical factors. Physicians do not change antihypertensive treatment in many uncontrolled cardiovascular patients because they considered it unnecessary, especially when the BP values are only slightly above the guideline target. It is possible that the guidelines may be correct, but there is also the possibility that the care by the physicians is appropriate since BP <130/80 mmHg is hard to achieve, and recent reviews suggest there is insufficient evidence to support such a low BP target.
    PLoS ONE 09/2011; 6(9):e24569. DOI:10.1371/journal.pone.0024569 · 3.23 Impact Factor
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    • "Hypertension affects more than 65 million Americans and more than 1 million veterans in the Veterans Administration (VA) [1,2]. Despite recent improvements in the detection and management of high blood pressure, studies suggest hypertension is still poorly controlled in at least half of VA patients, and likely more in other settings [1,3-6]. Guidelines suggest thiazide diuretics should be given as first-line therapy for uncomplicated hypertension and more frequently added to intensify existing regimens, but thiazides are under-utilized, and identification and appropriate treatment of patients with hypertension remains inadequate [4-8]. "
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    ABSTRACT: Hypertension guidelines recommend the use of thiazide diuretics as first-line therapy for uncomplicated hypertension, yet diuretics are under-prescribed, and hypertension is frequently inadequately treated. This qualitative evaluation of provider attitudes follows a randomized controlled trial of a patient activation strategy in which hypertensive patients received letters and incentives to discuss thiazides with their provider. The strategy prompted high discussion rates and enhanced thiazide-prescribing rates. Our objective was to interview providers to understand the effectiveness and acceptability of the intervention from their perspective, as well as the suitability of patient activation for more widespread guideline implementation. Semi-structured phone interviews were conducted with 21 primary care providers. Interviews were transcribed verbatim and reviewed by the interviewer before being analyzed for content. Interviews were coded, and relevant themes and specific responses were identified, grouped, and compared. Of the 21 providers interviewed, 20 (95%) had a positive opinion of the intervention, and 18 of 20 (90%) thought the strategy was suitable for wider use. In explaining their opinions of the intervention, many providers discussed a positive effect on treatment, but they more often focused on the process of patient activation itself, describing how the intervention facilitated discussions by informing patients and making them more pro-active. Regarding effectiveness, providers suggested the intervention worked like a reminder, highlighted oversights, or changed their approach to hypertension management. Many providers also explained that the intervention 'aligned' patients' objectives with theirs, or made patients more likely to accept a change in medications. Negative aspects were mentioned infrequently, but concerns about the use of financial incentives were most common. Relevant barriers to initiating thiazide treatment included a hesitancy to switch medications if the patient was at or near goal blood pressure on a different anti-hypertensive. Patient activation was acceptable to providers as a guideline implementation strategy, with considerable value placed on the activation process itself. By 'aligning' patients' objectives with those of their providers, this process also facilitated part of the effectiveness of the intervention. Patient activation shows promise for wider use as an implementation strategy, and should be tested in other areas of evidence-based medicine. National Clinical Trial Registry number NCT00265538.
    Implementation Science 03/2010; 5(1):24. DOI:10.1186/1748-5908-5-24 · 4.12 Impact Factor
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    • "As effective self-management of EH is a complex, multi-task process, involving a high level of pro-active commitment and self-control, poor self-management is a problem of equal magnitude in South-Africa as elsewhere (cf. Botha, Du Plessis, Van Rooyen & Wissing, 2002; Hamilton, 2003; Kruger & Gerber, 1998; Lahdenperä & Kyngäs, 2000; Steinman, et al., 2004). In a South-African sample, Botha et al. (2002) for example found that only 30.6% EH patients successfully applied self-management regarding medication and lifestyle prescriptions. "
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    ABSTRACT: The study investigated the subjective experiences of Essential Hypertension (EH) in a sample of urban white Afrikaans-speaking (n=25) and black Sotho-speaking (n=25) patients. Measures of self-management were obtained and their subjective experience of EH and its self-management was explored during brief, semi-structured interviews. Anger and stumbling blocks, for example forgetting to follow prescriptions, lack of motivation; and side effects of medication emerged as strong themes from all participants. Action-focused strategies were applied more often by self-managing articipants, in contrast to denial, which was more evident in non-self-managing participants. Illness misconceptions and family support emerged as strong themes from non-self-managing Sotho participants only. The implication of these results are discussed.
    Journal of Psychology in Africa 01/2009; 19(2). · 0.12 Impact Factor
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