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Provider Perspectives on Patient- and Provider-Facing High Blood Pressure Clinical Decision Support
David A Dorr1, Joshua E Richardson2, Michelle Bobo1
1Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States.
Insights
Provider management of high blood pressure (HBP) varies, despite guideline adherence challenges. Patient-facing decision support tools are accepted but must capture complex recommendations for effective HBP care.
Area of Science:
- Cardiology
- Health Informatics
- Clinical Practice Guidelines
Background:
- Persistent high blood pressure (HBP) is a major predictor of cardiovascular events.
- Inconsistent adherence to HBP guidelines by care teams and patients presents a significant challenge.
- Patient-facing clinical decision support (CDS) may improve adherence but requires clinician and patient acceptance.
Purpose of the Study:
- To understand provider variations and rationales concerning HBP guideline recommendations.
- To assess provider perceptions of the patient's role in HBP management.
- To explore provider views on the utility of digital tools for HBP care.
Main Methods:
- Iterative development and implementation of pilot and final surveys involving hypertension experts and primary care providers.
- Utilized five clinical cases to query clinician attitudes on HBP diagnosis, monitoring, and treatment.
- Descriptive analysis of Likert scale scores and content analysis of free-text responses.
Main Results:
- Most providers (>80%) deemed HBP guidelines important but found adherence difficult (up to 90% of the time).
- Perceptions of patient input and work in HBP management varied widely (22-100%).
- Providers expressed concerns about patient access, recommendation complexity, and understanding of digital tools.
Conclusions:
- Provider management of HBP is currently heterogeneous.
- Clinicians are receptive to patient-facing CDS but desire tools that reflect the complexity of HBP guidelines.
Background:
Hypertension, persistent high blood pressures (HBP) leading to chronic physiologic changes, is a common condition that is a major predictor of heart attacks, strokes, and other conditions. Despite strong evidence, care teams and patients are inconsistently adherent to HBP guideline recommendations. Patient-facing clinical decision support (CDS) could help improve recommendation adherence but must also be acceptable to clinicians and patients.
Objective:
This study aimed to partly address the challenge of developing a patient-facing CDS application, we sought to understand provider variations and rationales related to HBP guideline recommendations and perceptions regarding patient role and use of digital tools.
Methods:
We engaged hypertension experts and primary care respondents to iteratively develop and implement a pilot survey and a final survey which presented five clinical cases that queried clinicians' attitudes related to actions; variations; prioritization; patient input; importance; and barriers for HBP diagnosis, monitoring, and treatment. Analysis of Likert's scale scores was descriptive with content analysis for free-text answers.
Results:
Fifteen hypertension experts and 14 providers took the pilot and final version of the surveys, respectively. The majority (>80%) of providers felt the recommendations were important, yet found them difficult to follow-up to 90% of the time. Perceptions of relative amounts of patient input and patient work for effective HBP management ranged from 22 to 100%. Stated reasons for variation included adverse effects of treatment, patient comorbidities, shared decision-making, and health care cost and access issues. Providers were generally positive toward patient use of electronic CDS applications but worried about access to health care, nuance of recommendations, and patient understanding of the tools.
Conclusion:
At baseline, provider management of HBP is heterogeneous. Providers were accepting of patient-facing CDS but reported preferences for that CDS to capture the complexity and nuance of guideline recommendations.
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Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.