Review ArticleTranslation of hypertension treatment guidelines into practice: a review of implementation
Introduction
The initial Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure (JNC) issued the first widely acclaimed national guidelines for any chronic disease condition in 1976.1 Since then, many national guidelines for numerous conditions have been disseminated around the world. There has been the subsequent realization that highly evidence-based guidelines are necessary but insufficient to achieve good patient care outcomes. The science of implementation—the translation of hypertension treatment guidelines into practice—has proven to be at least as challenging as developing practice guidelines. At a recent National Heart, Lung, and Blood Institute workshop, implementation was defined as the “use of strategies to enhance adoption and integration of evidence-based health interventions into practice patterns within specific settings.”2 In anticipation of the JNC 8 guideline, discussion will subsequently turn to guideline implementation, closing the gap between knowledge and clinical practice.
Section snippets
What are the Barriers to Following Practice Guidelines?
A 1999 review modeled barriers into three categories: knowledge, attitude, and behavior.3 The knowledge barrier has to do with the volume of information and time to stay informed with a proliferation of guidelines and guidelines updates. Additionally, casual awareness does not carry sufficient detail for adequate application. When faced with a proliferation of information and practice demands, practitioners are compelled to perform their own prioritization, which may place hypertension
The Importance of Guideline Language
Implementation begins with the language of the guidelines themselves. The Guidelines International Network, founded in 2002 and representing 52 organizations from 27 countries, contains a database of more than 2000 guidelines and also offers “guideline for guidelines” training material which includes the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument for guideline appraisal.9 Although recently released AGREE II is a useful tool used to assess and improve the quality of
Multifactorial Educational Approaches Directed at Care Gaps and the Importance of Communication Skills to Supplement Guideline Knowledge
In the Department of Veterans’ Affairs (VAH) primer of guideline implementation, a literature search recognized several successful strategies that have been replicated in other health care systems. Multifaceted approaches to influence provider behavior should include multiple educational approaches.14 For more than a decade, the Carolinas-Georgia-Florida Chapter of the American Society of Hypertension (ASH) has coordinated education activities for providers in many settings. Case-based lectures
Audit and Feedback
An important principle of performance enhancement described in the 1998 VAH primer and confirmed in follow-up studies is that of audit and feedback.21 The usual audit measure is hypertension control performance in an individual practitioner’s patient panel, and the most productive feedback is provided in an unblinded fashion in group settings. Without feedback, providers tend to have an inflated perception of their performance. A barrier to unblinded performance feedback is the concern
Team-based Care
Another important learning aspect is the importance of team-based care to improve hypertension control, with recent evidence pointing to the significance of guideline-based algorithms to drive patient treatment. The number of patients with hypertension is daunting. According to the 2008 National Health and Nutrition Examination Survey (NHANES) report, 29% of the United States population, age 18 and older, have hypertension.23 The number of primary care physicians would be incapable of managing
Successful Implementation Experience of Large Integrated Health Care Systems
Large integrated health care delivery systems at the VAH and KP have been able to achieve significant quality improvements across populations using integrated multifaceted approaches.32, 33, 34 Both systems have emphasized the role of care managers in assisting physicians, coordinating health care teams, and facilitating communication between team members and patients. Contractual accountability for meeting performance targets at the VAH, and competitive rankings of care delivery teams between
Successful Implementation is Related to Blood Pressure Measurement Credibility
After addressing the findings of large multidisciplinary barrier analysis meetings citing lack of blood measurement competency and inadequate follow-up systems, the Mid-Atlantic States region of KP won a national KP quality improvement award in 2006 for controlling high blood pressure.33 More recent Colorado region KP analyses have also shown a positive relationship between blood pressure competency and hypertension control at the medical office building level.36 Providers appear more likely to
Role of the Medical Assistant in Checking Blood Pressure: Improving Health Care Access and Hypertension Control
Hypertension guideline implementation requires good access to care. In a 2010 Cochrane review of interventions to improve control of blood pressure in patients with hypertension, there was a strong correlation between regular surveillance and stepped care and hypertension control performance, dominated by findings from the Hypertension Detection and Follow-up Program.17 In SCPMG, more than 650,000 adults are included in the Hypertension Registry, representing 86% of the hypertension prevalence
Guideline Simplicity Promotes Implementation
A core characteristic relating hypertension treatment guidelines to implementation is simplicity. Simplicity strongly promotes successful implementation. The Seventh JNC on High Blood Pressure contains recommendations which have been adopted by the Care Management Institute of KP to develop a programwide treatment algorithm that is based on fixed-dose generic drug therapy followed by amlodipine and maximizes three drugs in six steps.38 Fixed-dose combination antihypertensive drugs have many
Therapeutic Inertia and Medication Adherence
Lack of treatment intensification despite blood pressure elevation is a well-studied phenomenon.40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 The underlying explanations for physician inertia is multifactorial related to soft reasoning, overestimation of care provided, concern directed at patient symptoms, unfamiliarity with guidelines, comanagement with subspecialties, and clinical uncertainty given an array of variable blood pressures originating in the office and at home.52 Provider
Evolving Role of the Electronic Health Record
Increasing availability of the electronic health record (EHR) holds promise for computerizing hypertension treatment guidelines in clinical decision support.64 Starting with very limited EHR prevalence in early 2009,65 the American Recovery and Reinvestment Act is expected to boost utilization enough that national strategies to use this new resource are in development. Enhanced documentation of hypertension by the EHR improves control at a very basic level,66 and is included in the “meaningful
Hypertension Treatment Guidelines at the Level of Patient Empowerment
Hypertension guideline implementation is also taking place in community clinics72 and at the level of patient empowerment.73, 74 Patient knowledge of goal blood pressure is associated with blood pressure control,75, 76, 77, 78 and several patient education campaigns in this country and abroad have emphasized “know your blood pressure” and “know your numbers.” Secure patient-physician email is a form of patient empowerment that has been associated with improved blood pressure control.79 Patient
Performance Measures are a Powerful Inducement for Guideline Implementation
Supported by the National Committee for Quality Assurance, Health Care Employer Data and Information Set (HEDIS) performance measures should be designed to support the JNC guidelines. Public reporting of health care measures is powerful inducement for health care plans and physicians to meet HEDIS benchmarks.81 In contrast, conflict between performance measures by which health plans are held accountable and a highly evidence-based national guideline would be expected to lead to provider
Generalizability
The issue of generalizability is closely tied to implementation because the context of an intervention often determines its success or failure.82, 83 A templated telephonic outreach to more than 30,000 patients with uncontrolled hypertension in SCPMG was credited with a 32% conversion to control at 4 weeks.84 That intervention occurred in the context of an integrated health care delivery system, which includes a hypertension registry with daily control rate updates, walk-in medical assistant
Who Should be the Target Audiences for Implementation of JNC 8?
Because hypertension is such a widespread condition and generates the most office visits of any chronic disease, interested audiences run the gamut of system-based and team-based care delivery. The adaptation of the guidelines into clinical practice is maximized by a well-coordinated approach that includes complete coverage of all parties involved in the hypertension treatment paradigm. Providers at all levels of training and career development will need to be familiar with the new hypertension
How Should Implementation Success of the JNC 8 Guidelines be Measured?
Traditional measures of success of previous JNC guidelines have been hypertension control rates and drug prescription patterns. The Healthy People 2010 goal hypertension control rate of 50% probably seemed unattainable when it was first proposed a decade ago,86 but the NHANES 2008 report indicated that goal was reached two years ahead of schedule.23 With a Healthy People 2020 plan in the works, it appears that a goal hypertension control rate of 70% would not be unreasonable. A much more highly
Acknowledgments
The authors acknowledge Eduardo Ortiz, MD, senior medical officer, National Heart, Lung, and Blood Institute for review of the manuscript; Joseph Young, MD, clinical hypertension lead, Kaiser Permanente Northern California, for data sharing and review of the manuscript; Roger Benton, PhD, program manager, Healthy Workforce, Southern California Permanente Medical Group, for the idea and creation of Figure 1; Rita Gevorkyan, senior consultant, Southern California Permanente Medical Group, for
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Conflict of interest: The authors declare no conflict of interest.