Abstract P318: Provider Barriers and Facilitators to Treatment Intensification for Patients With Uncontrolled Blood Pressure

Abstract

Background: Hypertension is the leading cause of cardiovascular disease and premature death worldwide, however, therapeutic inertia, failure to intensify pharmacotherapy when blood pressure (BP) is not at goal, is a key obstacle to hypertension control. We aimed to identify barriers and facilitators to increasing the dose or adding a different antihypertensive medication class for patients with uncontrolled BP. Methods: We conducted a qualitative study of healthcare providers from Kaiser Permanente Southern California (KPSC). Using a stratified purposeful sampling approach, we identified 300 providers across 15 medical centers and specialties and with a mix of treatment intensification rates. In 2 separate waves, we emailed a letter of invitation to 150 eligible providers followed by 2 reminder emails each two weeks apart. We sought to conduct 30 semi-structured interviews about management of patients newly diagnosed with hypertension including use of single-pill combination therapy (SPC) (the recommended first-line therapy within KPSC), barriers to therapeutic intensification and use of home BP monitoring for treatment intensification decision making. We used rapid analysis methods to code responses and develop themes. Results: A total of 11 interviews were completed with providers from family medicine (n=7), internal medicine (n=3) and cardiology (n=1) who had an average of 6 years of practice within KPSC. The majority of providers reported using monotherapy as first-line treatment while SPC therapy was reserved for younger patients and those with baseline systolic BP >160 mm Hg. Monotherapy was often preferred to help providers determine if the first-line medication is causing side effects. Nearly all providers reported maximizing the dose of one medication before adding another medication class. Providers ranked the barriers to intensifying patients’ treatment in order of importance as 1) side effects such as frequent urination, hyperkalemia, and hypotension, 2) nonadherence to the current antihypertensive medication regimen and patient preference/hesitancy, 3) comorbidities (e.g., kidney function), and 4) age-related factors such as memory loss and ability to complete follow-up labs. All providers reported using patients’ home BP readings for treatment decision-making with most recognizing that patients’ out-of-clinic BP may be lower than clinic BP. Conclusion: Providers embraced stepped-care treatment for newly diagnosed patients with hypertension with most preferring monotherapy as first-line treatment. Concerns with side effects, nonadherence to the medication regimen and shared decision-making are key factors in providers’ decisions to intensify therapy for patients with uncontrolled BP. Targeted interventions to address provider barriers to treatment intensification may be needed.