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Physician-Related Barriers to the Effective Management of Uncontrolled Hypertension
Susan A. Oliveria, ScD, MPH;
Pablo Lapuerta, MD;
Bruce D. McCarthy, MD;
Gilbert J. L'Italien, PhD;
Dan R. Berlowitz, MD;
Steven M. Asch, MD
Arch Intern Med. 2002;162:413-420.
ABSTRACT
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Background Primary care physicians may not be aggressive enough with the management
of hypertension. The purpose of this study was to identify barriers to primary
care physicians' willingness to increase the intensity of treatment among
patients with uncontrolled hypertension.
Methods Descriptive survey study. We sampled patient visits in a large midwestern
health system to identify patients with uncontrolled hypertension. The treating
primary care physicians were asked to complete a survey about the patient
visit with a copy of the office notes attached to the survey (patient visits,
n = 270; response rate, 86%).
Results Pharmacologic therapy was initiated or changed at only 38% of visits,
despite documented hypertension for at least 6 months before the patients'
most recent visit. The most frequently cited reason for no initiation or change
in therapy was related to the primary care physicians being satisfied with
the blood pressure (BP) value (satisfactory BP response, 30%; satisfactory
diastolic BP response, 16%; only borderline hypertension, 10%). At 93% of
these visits, systolic BP values were 140 mm Hg or higher, which is above
the cut point recommended by Sixth Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
guidelines, and 35% were 150 mm Hg or higher. On average, physicians reported
that 150 mm Hg was the lowest systolic BP at which they would recommend pharmacologic
treatment to patients, compared with 91 mm Hg for diastolic BP.
Conclusions Our findings suggest that an important reason why physicians do not
treat hypertension more aggressively is that they are willing to accept an
elevated systolic BP in their patients. This has an important impact on public
health because of the positive association between systolic BP and cardiovascular
disease.
INTRODUCTION
IMPROVING THE QUALITY of hypertension care is a priority. Studies have
shown that most patients with hypertension have inadequate blood pressure
(BP) control,1-7
resulting in excess cases of coronary artery disease, congestive heart failure,
renal insufficiency, peripheral vascular disease, and stroke.2, 8-11
Safe and effective therapies for hypertension are readily available, and the
importance of obtaining optimal BP control through the use of these therapies
is increasingly recognized. Efforts to understand poor BP control have usually
focused on patient adherence with therapy and patient characteristics associated
with nonadherence. Recently, it has been shown that clinician practices are
very important and that physicians may not be aggressive enough in their management
of hypertension.2, 5, 12-18
Further, despite the demonstrated positive association between systolic BP
and cardiovascular disease, there is uncertainty among physicians about the
importance of systolic BP.19-20
These results suggest the need for studies on patient-clinician interaction
and that better define how clinicians make decisions about therapy for the
hypertensive patient.
Investigators have suggested that barriers to the effective management
of patients with uncontrolled hypertension include patient management time
constraints, physician practice patterns, drug adverse effects, and the complexity
of prescribing and/or monitoring existing drug regimens.2, 15-16,21-27
There are also patient-specific factors that affect the successful management
of hypertension. These include lack of adherence to therapy, limited access
to care, financial barriers related to the cost of medications, and lack of
knowledge about the seriousness of uncontrolled hypertension.2, 21-22,25-38
The quality of the interaction between the patient and physician may also
be important in predicting the adequate delivery of medical care.12, 22, 39 Some studies suggest
that physicians do not conform to practice guidelines for treating hypertension,
although the reasons for this have not been adequately studied.2, 40-45
The purpose of the present study was to identify, in a primary care
setting, barriers to physicians' willingness to increase the intensity of
treatment among patients with uncontrolled hypertension as suggested by consensus
guidelines. We assessed familiarity and agreement with the Sixth Report of
the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC VI)2 hypertension
treatment guidelines, including the importance of systolic BP. These results
will provide important information to improve the quality of care in patients
with hypertension.
METHODS
We conducted a descriptive survey study to identify physician-related
barriers to the treatment of uncontrolled hypertension in a primary care setting.
We sampled patient visits during a specified 3-week period (October 4, 1999,
through October 22, 1999) to identify patients with uncontrolled hypertension
and then queried the treating physicians about barriers related to physicians'
willingness to increase the intensity of treatment. We also conducted patient
interviews to obtain information on patient characteristics that may be related
to hypertension management, including patient satisfaction with the BP treatment
plan.
STUDY SITE
This study was conducted at the Henry Ford Medical Group, which is part
of the Henry Ford Health System in Detroit, Mich. The Henry Ford Medical Group
(a system-affiliated, multispecialty, salaried physician group) provides most
of the care for the Henry Ford Health System and consists of 27 sites. To
ensure a high level of participation, we identified 1 geographic site within
the Henry Ford Health System where primary care physicians are willing to
participate and have had experience conducting quality of care research. We
limited our study to an insured patient population with a regular source of
care and a recent physician visit in the prior year because these factors
have been identified as correlates of controlled hypertension.30, 32, 46-49
The Henry Ford Health System contains automated medical databases for
all inpatient and outpatient encounters. Information on outpatient encounters
includes the date of visit, diagnoses, physician delivering care, procedures
delivered, clinic where the care was delivered, and charges compiled. Medical
records are maintained in both a traditional paper format and a computerized
system. The electronic medical record includes information on inpatient interim
and final diagnoses, discharge summaries, inpatient pharmacy, laboratory data,
appointments, outpatient visit diagnoses, physiologic measures (including
BP), and clinic office notes. The system is updated continuously and almost
immediately from the paper format to the electronic medical record.
ASCERTAINMENT OF PATIENTS WITH UNCONTROLLED HYPERTENSION
We identified all patients from the site of interest with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code of hypertension (401.0-401.9) during the prior
6 months who had at least 1 prior visit to a physician at the Henry Ford Health
System during the prior year. We then determined whether these patients had
a recent office visit (defined as the index visit) with an elevated BP (systolic
BP  140 mm Hg and or a diastolic BP 90 mm Hg) during a specified 3-week
interval using computerized outpatient visit data. Blood pressure readings
were abstracted for these patients from the computerized medical record. A
patient was classified as having uncontrolled hypertension if the average
BP reading for up to 6 visits during the 6 months prior to the index visit
was elevated.
PHYSICIAN QUESTIONNAIRE
For patients identified and defined as having uncontrolled hypertension,
we identified the primary care physician who treated the patient at the index
visit. The physician was then asked to complete a self-administered survey
about the patient visit, and a copy of the office notes for that visit was
attached to the survey. We developed this survey instrument based on work
done by Cabana et al50 with the goal of identifying
barriers to effective treatment of patients with uncontrolled hypertension.
The survey was administered to the physician for each patient visit of interest.
The survey included questions about any changes in hypertension medication
at the index visit and barriers related to this change in medication. Items
used to assess barriers included closed- and open-ended questions. The questionnaire
was pilot tested on a sample of 15 physicians who were not part of the final
study. We used pilot testing and informal focus group settings to further
obtain a list of barriers to treatment modification. A second one-time survey
that included questions about familiarity and agreement with JNC VI2 guidelines, target BP treatment goals, and physician
demographics and practice characteristics was also given to the physician.
PATIENT TELEPHONE INTERVIEWS
Patient telephone interviews were conducted to obtain information on
patient characteristics that may be related to hypertension management, including
patient satisfaction and adherence with BP treatment plan, age, race/ethnicity,
and educational level. The questionnaire was pilot tested and standardized
using trained interviewers at the Henry Ford Health System. Patients who were
identified as having uncontrolled hypertension were mailed an introductory
letter inviting them to participate in the study and stating that they would
be contacted by telephone to give consent and participate in a brief telephone
interview of approximately 10 minutes.
AUTOMATED DATA COLLECTION
Information was obtained from the computerized databases for each patient
on the duration of hypertension, number of physician visits and hypertension-related
visits during the prior year, and comorbidities. Electronic medical record
review was conducted by trained chart abstractors to collect detailed information
on the reason for the index visit, physician diagnosis of hypertension at
the index visit, current hypertension medications, family history of cardiovascular
disease, length of time under care of physician, and physician recommendation
to increase the intensity of BP therapy in the prior 6 months.
DATA ANALYSIS
We calculated descriptive statistics to characterize the distribution
of the study results at both the physician and patient level. Logistic regression
modeling was then used to identify predictors of the likelihood of physicians
to change medication or increase the intensity of treatment. Odds ratios,
confidence intervals, and P values (2-tailed) were
calculated for each variable in the model to quantify the association between
the factor of interest and the likelihood of the physician increasing the
intensity of treatment while controlling for other variables in the model.
Statistical analyses were performed using SAS statistical software (SAS Institute
Inc, Cary, NC).
RESULTS
We initially identified 5145 patients with an ICD-9 diagnosis code of hypertension during the prior 6 months who had at
least 1 visit during the prior year. None of the patients identified by our
algorithm had an ICD-9 code 401.0 (malignant hypertension).
Of these 5145 patients, 314 patients had an office visit during the 3-week
period of sampling and were classified as having uncontrolled hypertension.
At the study site, 21 (81%) of 26 physicians responded to the physician questionnaire
and provided information on 270 patient visits for a response rate of 86%.
Physicians may have completed surveys on multiple patients, and each physician
completed an average of 13 surveys. The time between the index visit and the
physician's completion of the survey ranged from 10 to 90 days (median, 55
days). Patient telephone interviews were attempted on the 314 patients; 15
patients were excluded during the interview process because they did not speak
English, were too sick to complete the interview, or were deceased. In total,
231 of 299 patients completed the telephone interview for a response rate
of 77%. The time between the index visit and patient telephone interview ranged
from 24 to 107 days (median, 61 days).
Characteristics of the patients who completed the interview are presented
in Table 1. The median age of
patients was 69 years (range, 25-96 years). The patient population was composed
of approximately 50% whites, 30% blacks, and 12% other races or ethnicities.
The patients' average BP value during the prior 6 months was 152 mm Hg for
systolic and 84 mm Hg for diastolic, with 94% of the patients currently taking
hypertension medication. The median age of the physicians was 42 years, and
all physicians were board certified in internal medicine. The median number
of years since completing residency was 9.5, and approximately one third of
the physicians were women. Characteristics of the patient visits are presented
in Table 2. Of the patient visits,
51% were for hypertension as indicated by the associated ICD-9 code.
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Table 1. Characteristics of 231 Patients With Uncontrolled Hypertension*
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Table 2. Characteristics of 231 Patient Visits*
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Physician familiarity and agreement with hypertension guidelines is
presented in Table 3. All physicians
were either very familiar or somewhat familiar with the JNC VI guidelines
for treating hypertension, and most agreed with these recommendations. About
62% of physicians reported that they "usually" follow JNC VI guidelines when
treating hypertensive patients, while 14% reported that they "always" follow
the guidelines. To assess physician awareness of uncontrolled hypertension,
we asked the respondents to estimate the percentage of treated hypertensive
patients who have their BP under control. Most physicians reported that they
believe that 50% to 60% of patients treated with hypertension medication have
controlled BP. Physicians were asked to estimate the risk associated with
specific examples of elevated diastolic and systolic BP and the lowest BP
at which they would recommend pharmacologic treatment. We did not account
for any recommended lifestyle changes but simply wanted to find out the thresholds
for pharmacologic treatment. On average, physicians reported that 150 mm Hg
was the lowest systolic BP at which they would recommend pharmacologic treatment
to patients, compared with 91 mm Hg for diastolic BP.
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Table 3. Physician Agreement and Familiarity With Awareness of Hypertension
Guidelines*
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We asked physicians to report treatment strategies for specific patient
visits (Table 4). Lifestyle modification
was recommended at 47% of the visits, while prescription medication for hypertension
was initiated or changed at only 38% of the visits, despite documented hypertension
for at least 6 months before the index visit. Of the visits at which medication
was initiated or changed (38%), more than 97% of the physicians reported initiating
drug treatment, increasing the dosage of current medication, or adding a new
drug to the existing regimen (Table 4).
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Table 4. Physician Treatment Strategies for Patients With Uncontrolled
Hypertension*
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Physician-related barriers to changing hypertension medication are presented
in Table 5. Of the 61% of patients
with no initiation or change in pharmacologic therapy, the most frequently
cited reason was related to the physician being satisfied with the BP value
(satisfactory BP response, 30%; satisfactory diastolic reading, 16%; only
borderline hypertension, 10%). Other reasons cited as barriers to initiating
or changing hypertension medication was that the focus of the visit was not
BP control and/or competing medical problems (29%) and that there was a need
to continue monitoring patient before changing drug regimen (35%). We further
assessed those patient visits at which there was no change in pharmacologic
therapy and the physician reported being satisfied. The distributions of the
systolic and diastolic BP measurements at the index visit are presented in Figure 1. At 93% of these visits, systolic
BP values were 140 mm Hg or higher, which is above the cut point recommended
by JNC VI guidelines, and 35% were 150 mm Hg or higher. Diastolic BP values
were 90 mm Hg or higher at 22% of the visits. For patient visits at which
the physician cited the need to continue monitoring the patient before changing
the drug regimen (n = 58), we explored the distribution of BP measurements
available during the prior 6 months. Only 20 (34%) had evidence of at least
1 measure indicating BP control.
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Table 5. Reason(s) for No Initiation or Change of Hypertension Medication*
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A, Systolic blood pressure (BP) for 72 patients with no initiation
or change of hypertension medication. B, Diastolic BP for 72 patients with
no initiation or change of hypertension medication. Reasons given for no initiation
or change in hypertension included satisfactory BP response, diastolic BP
reading was satisfactory, or only borderline hypertension.
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We explored potential predictors of the physician increasing the intensity
of hypertension treatment, including physician characteristics, physician
familiarity and agreement with JNC VI guidelines, patient demographics, comorbidities,
reason for visit, physician diagnosis of hypertension at visit, length of
time under care of physician, patient satisfaction, level of BP control, previous
recommendation to increase BP therapy, and number of current hypertension
medications being taken. Logistic regression modeling identified level of
BP control and previous recommendation to increase the intensity of BP therapy
as predictors of the physician initiating or changing therapy. The variable
for number of current hypertension medications did not reach statistical significance
in the model, but it was associated with an increased likelihood of the physician
initiating or changing therapy (Table 6).
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Table 6. Multivariate Logistic Regression Analysis of Factors Associated
With Physician Increasing Intensity of Treatment*
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Not only did physicians not describe adherence to therapy as a barrier
to control, but patients also reported a high level of compliance with therapy.
Additionally, patients were very satisfied with care even though their BP
was not controlled.
COMMENT
Uncontrolled hypertension is a significant public health problem with
only about 25% of patients having adequate BP control. This has the potential
to make a significant impact on the morbidity and mortality associated with
cardiovascular disease and stroke. Understanding the ways in which physicians
manage hypertension and the process of care is important, especially their
willingness to be more aggressive with hypertension therapy.
We conducted this descriptive survey in primary care physicians and
their patients with uncontrolled hypertension to identify barriers to physicians'
willingness to increase the intensity of hypertension treatment. Pharmacologic
therapy was initiated or changed at only 38% of patient visits, despite the
fact that hypertension was recorded as uncontrolled for at least 6 months
before the index visit. Our study demonstrated that the most frequently cited
barrier to changing hypertension medication was the physician was satisfied
with the existing BP value. Consistent with our study, Berlowitz et al5 have suggested that physicians are not aggressive
with the management of hypertension and have shown that patients with hypertension
have inadequate control of their BP. Failure of physicians to increase or
change therapy and the administration of low dosages of antihypertensive medication
have also been cited in JNC V1 and JNC VI2 reports as reasons for poor BP control. Our study
findings suggest that the level of BP control, a previous recommendation to
increase BP therapy, and number of current hypertension medications are predictors
of a physician initiating or changing therapy, which is consistent with the
findings of Berlowitz et al.5
Our findings, based on the survey responses and medical record review,
suggest that physicians place more importance on the diastolic BP reading
than the systolic BP reading. At patient visits for which there was no change
or initiation in hypertension therapy, systolic BP values were above the 140
mm Hg cut point recommended by the JNC VI guidelines. Typically, physicians
stated that they were satisfied with the level of BP control at the index
visit despite the elevated systolic BP. This is supported by the finding that
physicians reported that, on average, 150 mm Hg was the lowest systolic BP
at which they would recommend pharmacologic treatment to the patient, compared
with 91 mm Hg for diastolic BP. In addition, when asked to estimate the risk
associated with specific examples of elevated diastolic and systolic BP, physicians
attributed a higher risk to elevated diastolic BP. Physicians reported being
familiar and in agreement with the JNC VI guidelines, with more than 75% of
physicians reporting that they "always" or "usually" follow JNC VI guidelines
when treating hypertensive patients. Physicians may not understand the risk
associated with an elevated systolic BP and are thus focusing on the diastolic
reading, or they may be knowledgeable about the risk but do not incorporate
this into their practice patterns. This highlights the difficulties in implementing
clinical guidelines.41, 50 Further,
most physicians reported that they believe that 50% to 60% of patients treated
with hypertension medication have controlled BP. Based on the Third National
Health and Nutrition Examination Survey data, 45% of treated hypertension
patients had BP control, and only 34% of all patients with hypertension were
at or below the systolic BP goal of 140 mm Hg.4, 51
Few studies have examined physician-related barriers to the management
of uncontrolled hypertension. A physician survey (N = 3740) conducted by the
National Heart, Lung, and Blood Institute52
assessed barriers to the effective control of BP. Physicians from general
and family practice, cardiology, and internal medicine specialties reported
on both patient- and physician-related factors, although the list of possible
factors was not comprehensive. The most frequently cited impediments to BP
control were lifestyle changes (67%), failure to take medications as instructed
(42%), patient lack of understanding of the problem (39%), physician fees
(23%), costs of drugs (39%), and drug adverse effects (34%). In a large survey
conducted in Europe of more than 11 000 cardiovascular patients receiving
hypertension treatment, 84% of the patients had an unchanged treatment even
though target BP goals were not achieved.17
However, these same physicians reported that they would be willing to change
medications by increasing the dosage, adding a new drug, or switching drugs.14-15,17 These studies and
ours emphasize that both physician and patient factors are important in the
control of BP.
Patient adherence has been identified as one of the main reasons that
BP therapy fails.1-2,22
The complexity of the regimen including multiple drugs and dosages is likely
to be related to compliance.22, 24, 37, 53
We hypothesized that significant barriers to the management of uncontrolled
hypertension would include patient compliance, patient acceptance, and complexity
of the drug regimen. However, physicians did not report these factors as important
barriers to changing or initiating hypertension medication therapy. Patients
who have more aggressive therapy may be less satisfied with their medical
care. We had the opportunity to ask patients questions related to compliance
and satisfaction. Almost all patients reported that they followed their physicians'
recommendations concerning BP medication and were satisfied with their treatment
and medications.
Drug adverse effects have also been identified as a factor related to
physician prescribing patterns of hypertensive medications. In a study by
Ekpo et al,54 the reason most often mentioned
for not using drug therapy to treat isolated systolic hypertension was reduced
quality of life due to adverse effects. Lip and Beevers25
surveyed primary care physicians (n = 178) and their patients (n = 948). Of
all switches in antihypertensive drug therapy, 42% occurred because patients
experience adverse effects. In another survey of 500 adults with hypertension,
11% reported stopping hypertension medication because of adverse effects,
and 47% of the patients reported adverse effects as the most important attribute
of medication.27 In our study, adverse effects
were not reported as an important barrier to pharmacologic treatment changes.
No other study to our knowledge has looked at barriers to physicians'
willingness to change hypertension medications and the intensity of treatment.
We had the ability to conduct semistructured surveys about specific patient
visits to elicit a range of barriers to understand the obstacles to effective
treatment of hypertension. We believe our approach provides more detailed
and specific information directly related to patients with uncontrolled hypertension
compared with a simple checklist approach.
There are several limitations to this study. The selection of a single
site within the Henry Ford Health System to conduct this study may limit the
generalizability of these findings to populations with limited access to care
and to other physicians. However, based on the complexity of this study design,
we used the resources available to obtain specific and detailed information
from physicians, patients, and medical records. We focused our efforts on
obtaining participation from both physicians and patients, which is evident
from the high response rates obtained for this survey study.
The physicians at the Henry Ford Health System are similar to private
practice physicians in that they have few constraints related to providing
care to their patients. There is no formal continuing medical education program,
and physicians obtain additional education on their own.
The algorithm we used to screen and identify patients with hypertension
may have missed some patients with uncontrolled hypertension. However, our
goal was not to assess the prevalence of uncontrolled hypertension, but to
sample patient visits and describe barriers to effective management of uncontrolled
hypertension. We believe the approach we used to identify and define patients
with uncontrolled hypertension using claims data and medical records is valid
based on work done by others.6, 55-56
There is no standardized instrument available to assess physician-related
barriers to hypertension treatment. To minimize bias, questions were asked
in the context of the medical management of the patient, and physicians were
informed that the overall goal of the study was to identify physician-related
barriers to the effective treatment of uncontrolled hypertension. These results
suggest the need for studies on the patient-clinician interaction and for
studies that better define how clinicians make decisions about therapy for
the hypertensive patient. The median time between the index visit and physician
completion of the survey was 55 days. There may be inherent limitations with
this approach if the physician had difficulty recalling details of the patient
visit; therefore, we attached a copy of the office notes for the index visit
to the physician questionnaire. Likewise, the median time between the index
visit and patient telephone interview was 61 days with the potential for recall
bias. However, information on such factors as age, sex, and race/ethnicity
that was obtained from the patient interview is unlikely to be biased.
To achieve the ultimate goal of improving health by controlling hypertension,
it is important to fully understand the obstacles that physicians encounter
while providing care. Our findings suggest that an important reason why physicians
do not treat hypertension more aggressively is that they are willing to accept
an elevated systolic BP in their patients. Our findings seem to suggest that
physicians are familiar with the guidelines for treating hypertension but
do not implement this knowledge into their everyday practice. This has an
important public health impact because of the positive association between
systolic BP and cardiovascular disease. The findings of this study provide
useful information for designing effective physician interventions for the
management of patients with uncontrolled hypertension.
AUTHOR INFORMATION
Accepted for publication July 16, 2001.
This research was supported by a grant from Bristol-Myers Squibb Company,
New York, NY. Dr Asch is supported by a Veterans Administration Health Services
Research and Development Career Development Award.
We thank Joanna L. Whyte, MS, RD, MSPH, for her review and helpful comments
on the manuscript.
Corresponding author and reprints: Susan A. Oliveria, ScD, MPH, Memorial
Sloan-Kettering Cancer Center, 1275 York Ave, Box 99, New York, NY 10021 (e-mail: oliveri1{at}mskcc.org).
From The Epigroup, Galt Associates, Inc, and the Departments of Public
Health, Weill Medical College of Cornell University and Medicine, Memorial
Sloan-Kettering Cancer Center (Dr Oliveria), New York, NY; Pharmaceutical
Research Institute, Bristol-Myers Squibb Company, Princeton, NJ (Drs Lapuerta
and L'Italien); Henry Ford Health System, Detroit, Mich (Dr McCarthy); Center
for Health Quality, Outcomes, and Economic Research and Bedford VA Hospital,
Bedford, and Boston University School of Medicine, Boston (Dr Berlowitz),
Mass; and West Los Angeles Veterans Administration Medical Center, Los Angeles,
University of California, Los Angeles, and RAND, Santa Monica (Dr Asch), Calif.
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