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Yuan Lu, ScD, discusses a novel classification system she and colleagues developed to improve clinician adherence to hypertension treatment guidelines.

Guidelines for severe hypertension management exist, yet clinicians tend not to adhere to them. A new classification system identifies causes for this gap and suggests approaches to improve adherence, according to findings published in JAMA Network Open.

“This study found that clinicians may refrain from starting or intensifying blood pressure treatment due to various challenges, including clinician-related factors, patient preferences, nonadherence to medications, and complex clinical situations. Addressing these barriers could improve the quality of care and ensure that more patients receive the treatments they need,” study author Yuan Lu, ScD, tells Physician’s Weekly.

In their content analysis, Dr. Lu and colleagues investigated factors influencing clinician nonadherence to current hypertension management guidelines. They reviewed patient EHRs for 20,654 individuals who met inclusion criteria: at least two consecutive visits with markedly elevated blood pressure (systolic ≥160 mm Hg and diastolic ≥100 mm Hg), with no antihypertensive drug prescription within 90 days of the second BP measurement.

The 100 participants (50% women; 85% White) randomly selected for analysis averaged 66.5 years at the index visit.

Areas for Improvement

From their review, the researchers developed a taxonomy of scenarios involved in treatment non-initiation or non-intensification. This taxonomy included:

• Clinician-related scenarios related to intention, capability, or scope, including not addressing treatment initiation or intensification OR diffusion of responsibility;
• Patient-related scenarios due to patient behavioral considerations, including patient nonadherence and patient preference;
• Scenarios related to clinical complexity, including diagnostic uncertainty or maintenance of current intervention; and
• Competing medical priorities.

Dr. Lu and colleagues identified several plausible contributing factors, including lack of clear protocols and processes to implement guidelines, infrastructure limitations, lack of clinician autonomy and authority, heavy workload, time constraints, and clinicians’ belief that hypertension management is another clinician’s responsibility.

Dr. Lu talked with Physician’s Weekly (PW) about how the results may improve clinician compliance and patient outcomes.

PW: What drew you and your colleagues to this research? 

Yuan Lu, ScD: This study was essential because high blood pressure is a leading cause of severe health complications, and it’s well-known that adhering to clinical guidelines can reduce these risks. Even though guidelines are available, doctors often don’t follow them, leading to missed opportunities to control blood pressure. Understanding the reasons behind this nonadherence allows us to develop better support systems and interventions that align care with evidence-based guidelines.

The results were not entirely surprising, as the study confirmed many factors already suspected to contribute to poor guideline adherence. However, the depth of specific barriers—such as clinician-related scenarios, including “diffusion of responsibility,” where doctors pass off responsibility for managing blood pressure—was more pronounced than expected. This underscores the complexity of decision-making in healthcare.

What strengths or limitations of the study are noteworthy?

One strength is the use of real-world data from EHRs, which provides a pragmatic view of how care is delivered in actual clinical settings. A limitation is that the study was conducted in a single academic health system, which may not fully capture the diversity of practices in other regions or healthcare settings. Also, the study may not account for all the nuances of clinician decision-making as documented in health records.

How may these results help improve patient outcomes?

By identifying the main barriers to following blood pressure guidelines, healthcare systems can design more effective interventions, such as better decision support tools and clearer treatment processes. This could lead to improved blood pressure management, reducing the risk for complications like heart attack and stroke.

Clinicians should remain aware of the importance of timely treatment for severely elevated blood pressure and the need to follow guidelines actively. Engaging patients in discussions about their preferences and adherence to medication while addressing organizational challenges like workloads and role clarity can help bridge the gap in guideline adherence. Collaborating with other healthcare professionals, such as pharmacists and nurse practitioners, may also lighten the load and improve patient outcomes.

What further related research are you planning?

One unanswered question is how patient-specific factors, such as socioeconomic status or health literacy, intersect with clinician adherence to guidelines. We plan to conduct in-depth qualitative interviews with patients and clinicians in a future study to explore the nuances of these barriers. Future research will also focus on evaluating whether implementing EHR-based decision-support tools can effectively reduce the identified barriers and improve blood pressure management.