Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut.
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
JAMA Netw Open. 2024 Aug 1;7(8):e2426135. doi: 10.1001/jamanetworkopen.2024.26135.
Hypertension poses a substantial public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal.
To develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System included participants who had at least 2 consecutive visits with markedly elevated blood pressure (BP; defined as at least 2 consecutive readings of systolic BP ≥160 mm Hg and diastolic BP ≥100 mm Hg) between January 1, 2013, and December 31, 2021, and no prescription for antihypertensive medication within a 90 days of the second BP measurement. Data analysis was conducted from January to December 2023.
The primary outcome was scenarios and influencing factors contributing to clinician nonadherence to the guidelines for hypertension management. A thematic analysis of EHR data was conducted to generate a pragmatic taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension.
Of the 20 654 patients who met criteria, 200 were randomly selected and thematic saturation was reached after analyzing 100 patients (mean [SD] age at index visit, 66.5 [12.8] years; 50 female [50%]; 8 Black [8%]; 5 Hispanic or Latino [5%]; 85 White [85%]). Three content domains emerged: (1) clinician-related scenarios (defined as noninitiation or nonintensification of treatment due to issues relating to clinician intention, capability, or scope), which included 2 subcategories (did not address and diffusion of responsibility); (2) patient-related scenarios (defined as noninitiation or nonintensification of treatment due to patient behavioral considerations), which included 2 subcategories (patient nonadherence and patient preference); and (3) clinical complexity-related scenarios (defined as noninitiation or nonintensification of treatment due to clinical situational complexities), which included 3 subcategories (diagnostic uncertainty, maintenance of current intervention, and competing medical priorities).
In this qualitative study of EHR data, a taxonomy of suboptimal adherence scenarios for severe hypertension was developed and barriers to guideline adherence were identified. This pragmatic taxonomy lays the foundation for developing targeted interventions to improve clinician adherence to guidelines and patient outcomes.
高血压是一个重大的公共健康挑战。尽管有高血压管理的临床实践指南，但临床医生对这些指南的依从性仍然不理想。
为严重高血压的不依从治疗方案制定分类法，并确定遵医嘱指南的障碍。
设计、地点和参与者：本研究采用耶鲁纽黑文卫生系统的电子健康记录（EHR）进行定性内容分析，纳入了 2013 年 1 月 1 日至 2021 年 12 月 31 日期间至少有 2 次连续就诊且血压明显升高（定义为至少连续 2 次收缩压≥160mmHg 和舒张压≥100mmHg）的患者，并且在第二次血压测量后 90 天内没有开降压药。数据分析于 2023 年 1 月至 12 月进行。
主要结果是导致临床医生不遵守高血压管理指南的方案和影响因素。对 EHR 数据进行主题分析，以生成严重高血压管理中临床医生不遵守指南的治疗方案的实用分类法。
在符合标准的 20654 名患者中，随机选择了 200 名患者，在分析了 100 名患者后达到了主题饱和（指数就诊时的平均[标准差]年龄，66.5[12.8]岁；女性 50 名[50%]；黑人 8 名[8%]；西班牙裔或拉丁裔 5 名[5%]；白人 85 名[85%]）。出现了 3 个内容领域：（1）临床医生相关方案（由于与临床医生意图、能力或范围有关的问题而未开始或未加强治疗），包括 2 个亚类（未处理和责任扩散）；（2）患者相关方案（由于患者行为考虑而未开始或未加强治疗），包括 2 个亚类（患者不依从和患者偏好）；和（3）临床复杂性相关方案（由于临床情况复杂而未开始或未加强治疗），包括 3 个亚类（诊断不确定性、维持当前干预措施和竞争医疗优先级）。
在这项对 EHR 数据的定性研究中，制定了严重高血压不依从治疗方案的分类法，并确定了遵医嘱指南的障碍。这种实用的分类法为开发旨在提高临床医生对指南的依从性和患者结局的针对性干预措施奠定了基础。
