Identifying barriers to hypertension guideline adherence using clinician feedback at the point of care

Abstract

Factors contributing to low adherence to clinical guidelines by clinicians are not well understood. The user interface of ATHENA-HTN, a guideline-based decision support system (DSS) for hypertension, presents a novel opportunity to collect clinician feedback on recommendations displayed at the point of care. We analyzed feedback from 46 clinicians who received ATHENA advisories as part of a 15-month randomized trial to identify potential reasons clinicians may not intensify hypertension therapy when it is recommended. Among the 368 visits for which feedback was provided, clinicians commonly reported they did not follow recommendations because: recorded blood pressure was not representative of the patient's typical blood pressure; hypertension was not a clinical priority for the visit; or patients were nonadherent to medications. For many visits, current quality-assurance algorithms may incorrectly identify clinically appropriate decisions as guideline nonadherent due to incomplete capture of relevant information. We present recommendations for how automated DSSs may help identify "apparent" barriers and better target decision support.

Figures

Figure 1

Checklist of reasons for not adhering to a displayed drug recommendation

Figure 2

Frequency of potential barriers to guideline adherence, among high-BP visits with barriers-related feedback and no intensification of therapy (n=368)* *Multiple responses were allowed. Percentages do not sum to 100%.

Figure 3

Frequency of specific patterns of potential barriers, among high-BP visits with barriers-related feedback and no intensification of therapy (n=368)

Figure 4

Frequency of “other patient factors” themes, among high BP-visits with barriers-related feedback and no intensification of therapy (n=368)* *Multiple responses were allowed. Percentages do not sum to 100%.