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Factors Associated with Treatment Intensification for Uncontrolled Hypertension in a US Health System
Jaejin An1,2, Teresa N Harrison3, Liang Ni3
1Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA. jaejin.x.an@kp.org.
Insights
Therapeutic inertia is common in hypertension management, with only 29% of patients receiving treatment intensification. Team-based BP clinics improved intensification rates, highlighting the need for targeted interventions to enhance blood pressure control.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Therapeutic inertia, a significant barrier to effective blood pressure (BP) control, necessitates investigation into factors influencing treatment intensification.
- Uncontrolled hypertension remains a major global health concern, underscoring the need for optimized management strategies.
Purpose of the Study:
- To identify demographic, clinical, and health system factors associated with treatment intensification for uncontrolled hypertension.
- To compare treatment intensification rates between in-person medical office visits and team-based BP clinic encounters.
Main Methods:
- A mixed-methods approach combining quantitative analysis of electronic health records (EHRs) and qualitative insights from 11 semi-structured provider interviews.
- Analysis of EHR data from 221,519 adult patients with uncontrolled hypertension (BP ≥ 140/90 mm Hg) at Kaiser Permanente Southern California from 2018, followed for 6 months.
- Treatment intensification was defined as increasing medication dosage or adding new antihypertensive classes; multivariable regression identified associated factors.
Main Results:
- Only 29% of patients with uncontrolled BP experienced treatment intensification.
- Older age (≥ 76 years) and diabetes were associated with lower odds of treatment intensification.
- Team-based BP clinic encounters demonstrated higher odds of treatment intensification (OR=1.23) compared to standard office visits.
- Provider interviews revealed concerns regarding side effects, medication nonadherence, and shared decision-making as key barriers to intensifying therapy.
Conclusions:
- Less than one-third of patients with uncontrolled hypertension received intensified treatment, indicating a persistent therapeutic inertia.
- Team-based BP clinics facilitate more frequent treatment intensification, suggesting their potential for improving hypertension management.
- Targeted interventions addressing identified barriers are crucial for enhancing blood pressure control and reducing cardiovascular risk.
Background:
Therapeutic inertia is a key barrier to blood pressure (BP) control.
Objectives:
To identify demographic, clinical, and health system factors associated with treatment intensification for uncontrolled hypertension including in-person medical office versus team-based BP clinic encounters.
Design And Participants:
This mixed-methods study included a quantitative analysis of electronic health records and 11 semi-structured provider interviews from Kaiser Permanente Southern California (KPSC). This study included KPSC adults with hypertension and uncontrolled BP (≥ 140/ ≥ 90 mm Hg) during office encounters in 2018, followed for 6 months.
Main Measures:
Treatment intensification defined as increasing dose or adding a new class of antihypertensive medications, and 6-month BP reduction associated with treatment intensification. Multivariable regression analyses were used to identify factors associated with treatment intensification. Themes around barriers and facilitators of treatment intensification were developed from the provider interviews.
Results:
Among 221,519 patients with uncontrolled BP, 29% received an increased dose or added medications. Mean (SD) 6-month systolic BP reductions were 16.6 (14.3) mm Hg and 11.7 (13.5) mm Hg for those with treatment intensification versus not (p < 0.01). Older age (OR for age ≥ 76 vs 18-55 years = 0.68; 95% CI 0.65, 0.71) and having diabetes (OR = 0.86; 95% CI 0.84, 0.88) were associated with lower odds of treatment intensification; while team-based BP clinic encounters were associated with higher odds of treatment intensification (OR = 1.23; 95% CI 1.20, 1.27). Provider interviews showed concerns about side effects, medication nonadherence, and shared decision-making are key factors in decisions to intensify therapy.
Conclusions:
Less than one-third of patients with uncontrolled BP received increased hypertension medication doses, with more frequent intensifications in team-based BP clinics. Targeted interventions to address the identified barriers are needed to improve BP control.
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