Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review

Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records

IMPORTANCE

Hypertension poses a significant public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal.

OBJECTIVE

This study aims to develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence.

DESIGN

We conducted a qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System who had at least two consecutive visits between January 1, 2013, and October 31, 2018.

SETTING

This was a thematic analysis of EHR data to generate a real-world taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension.

PARTICIPANTS

We identified patients with markedly elevated blood pressure ([BP]; defined as at least 2 consecutive readings of BP ≥160/100 mmHg) and no prescription for antihypertensive medication within a 90-day of the 2nd BP elevation (n=4,828). We randomly selected 100 records from the group of all eligible patients for qualitative analysis.

MAIN OUTCOMES AND MEASURES

The scenarios and influencing factors contributing to clinician non-adherence to the guidelines for hypertension management.

RESULTS

Thematic saturation was reached after analyzing 100 patient records. Three content domains emerged: clinician-related scenarios (neglect and diffusion of responsibility), patient-related scenarios (patient non-adherence and patient preference), and clinical complexity-related scenarios (diagnostic uncertainty, maintenance of current intervention and competing medical priorities). Through a metareview of literature, we identified several plausible influencing factors, including a lack of protocols and processes that clearly define the roles within the institution to implement guidelines, infrastructure limitations, and clinicians' lack of autonomy and authority, excessive workload, time constraints, clinician belief that intervention was not part of their role, or perception that guidelines restrict clinical judgment.

CONCLUSIONS AND RELEVANCE

This study illuminates reasons for suboptimal adherence to guidelines for managing markedly elevated BP. The taxonomy of suboptimal adherence scenarios, derived from real-world EHR data, is pragmatic and provides a basis for developing targeted interventions to improve clinician guideline adherence and patient outcomes.

Two Decades of Overuse and Underuse of Interventions for Primary and Secondary Prevention of Cardiovascular Diseases: A Systematic Review

Quality use of anti-hypertensive and cholesterol-lowering medications is crucial for successful cardiovascular disease management. This systematic review aimed to estimate levels of over and underuse of services for primary and secondary prevention of cardiovascular diseases from 2000 to 2020: overprescribing/underprescribing, overtesting/undertesting and overutilization/ underutilization of procedures compared to clinical practice guideline recommendations. Thirteen studies from USA, Europe, Asia and Australia were included. Wide practice variation was identified. Six studies reported overuse (eg, perioperative cardiac consultations, anti-hypertensive overprescribing for normotensive or pre-hypertensive people); and ten studies reported underuse (eg, under-prescribing of statins when indicated and under-screening for familial hypercholesterolemia). Lifestyle recommendations for cardiovascular disease prevention were largely underused. In summary, lack of adherence to published guidelines was prevalent over the past 2 decades for both primary and secondary prevention across settings. Further investigation of potentially justifiable deviations from guidelines are warranted to verify the estimates and identify points for intervention.