Identifying gaps between guidelines and clinical practice in the evaluation and treatment of patients with hypertension

Abstract

Purpose Hypertension remains uncontrolled in the majority of affected patients despite treatment. Our goal was to identify specific action items in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) guidelines that are not being translated into clinical practice. Methods We transformed the major JNC VI tables into a chart review instrument that was used to retrospectively analyze the medical records of 249 patients with newly diagnosed hypertension who had been followed for 18 months at one of six community-based primary care clinics. Results The practices of physicians deviated from the guidelines in several ways. Hypertension was staged initially on a single blood pressure recording in 85% (n = 212) of patients. No electrocardiogram was ordered for 89% (n = 221) of patients, while other mandatory laboratory tests were ordered for about 50%. After 18 months, 40% (72/179) of patients for whom prescription records were identified were still on monotherapy, and target blood pressure (<140/90 mm Hg) was achieved in only 33% (83/249) of patients. All of the 35 patients with diabetes received an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, but only 1.7 medications were prescribed per patient at study end. Conclusion In this clinic system, staging of blood pressure with multiple measurements, thorough assessment of global cardiovascular risk, and titration of multiple antihypertensive medications to achieve blood pressure goal are components of the JNC VI guidelines that are not well translated into clinical practice. Overcoming these practice defects will require innovative multilevel interventions.