Previous studies have indicated that adherence to widely accepted clinical practice guidelines for hypertension such as JNC and VA is poor. Decision support systems (DSS) such as ATHENA DSS, a guideline-based DSS for hypertension, integrate best practices into clinical workflow. It is important to identify factors that impede or support the process of managing patients in accordance with the guidelines as is defined in QUERI Step 3. To assess some of the challenges that clinicians face working with guidelines to improve BP control, we analyzed feedback given by physicians at the point-of-care.
ATHENA DSS provides treatment advisories to clinicians about their hypertensive patients in primary care clinics based on national guidelines for hypertension (JNC and VA). One feature of ATHENA DSS is a feedback window that allows clinicians to enter free text comments. Feedback comments were reviewed and categorized for the principle ideas expressed by consensus of ATHENA team members. We report comments from clinicians who received ATHENA recommendations over a 15-month period at three VA medical centers.
A total of 835 comments were submitted by 48% (44 of 91) of clinicians on 735 patients who received ATHENA recommendations (mean = 19 comments/clinician respondent). Seventy-eight percent (650/835) of the comments discussed barriers to guideline adherence. Reasons clinicians cited for not intensifying hypertensive therapy included blood pressure values not representative of the patient's typical blood pressure (28%; 235), lack of patient adherence to medication (11%, 91), and a patient preference not to change to guideline-recommended therapy (3%; 49).
Clinician comments during the use of point-of-care decision support revealed some important barriers to use of best practices by clinicians. Our findings indicate that clinicians believe that for many patients, some decisions not to intensify therapy in the face of elevated blood pressures appear to be justified.