Fixed-Dose Combinations for Hypertension: Barriers to Use and Opportunities for Health Systems

Uncontrolled hypertension is a leading driver of heart disease, chronic kidney disease, heart failure, dementia, stroke, and pregnancy-related complications. Fixed-dose combinations (FDCs) are guideline-endorsed first-line therapies that improve blood pressure control by reducing pill burden, improving adherence, and targeting multiple pathophysiological mechanisms. However, FDC utilization remains low across U.S. health systems. Few studies examine the factors influencing FDC uptake; existing qualitative studies rarely interrogate structural barriers or formulate stakeholder-informed recommendations.

We explored the perspectives of providers, population health stakeholders, and health system executives through semi-structured interviews/thematic analysis to identify structural and provider-level barriers to FDC utilization and formulate recommendations for health systems.

Structural barriers included low exposure to FDCs early in training, entrenched monotherapy-reliant cultures, workflow constraints, fragmented formularies, and absent performance incentives and leadership endorsements. Provider-level perspectives and practices diverged: clinicians reported minimal use of FDCs, limited familiarity with FDCs, and concerns about dosage inflexibility and adverse effects. By contrast, pharmacists and nurse practitioners identified as major proponents of FDCs, demonstrated broad familiarity with therapeutic and cost advantages, and reframed clinicians concerns as misconceptions due to limited exposure.

To improve FDC utilization, we propose: (1) integrating FDC exposure into early medical and pharmacy curricula; (2) embedding decision-support tools and SmartSets that prompt FDC consideration into electronic medical records; (3) expanding team-based care models to distribute responsibility for medication intensification; (4) securing leadership endorsements, novel incentive structures for providers, and data tracking mechanisms; and (5) fostering normative change through champions, CME-accredited workshops, and socialization strategies.