Improving Hypertension Therapy Compliance with Systems-Level Interventions

Introduction: ACC/AHA clinical practice guidelines recommend initial dual-agent pharmacotherapy for Stage II HTN (BP >140/90), with growing evidence favoring single-pill combination (SPC) agents. At our urban VA Medical Center, most newly treated patients received monotherapy and available SPCs were underused. Hypothesis: We hypothesized that a systems-level quality improvement (QI) intervention targeting primary care providers (PCP) would increase initial dual-agent therapy and SPC use in patients with SBP>140 compared to historical controls. Methods: A multidisciplinary task force collaborated with stakeholders and experts to redesign the antihypertensive ordering menu as a decision support tool to align prescribing with guidelines. The updated menu promotes initial dual-agent therapy, prioritizing first-line medications and available SPC options. Simultaneously, PCPs were engaged through targeted education via posters and presentations. EHR data were extracted for pre- (Jan 2023-Dec 2023) and post-intervention (Aug 2024-Mar 2025) cohorts ( Figure 1 ). Study patients had SBP>140 at a PCP visit and were newly initiated on HTN pharmacotherapy. Analyses used t-tests and chi-square in Excel. Results: Pre-intervention, 25.5% (147/612) of patients with SBP>140, including 29.4% (65/221) with SBP >160, were prescribed initial dual-agent therapy. SPCs were used in 12.4% (76/612) of patients with SBP > 140 and 14.0% (31/221) with SBP>160. Post-intervention, 42.5% (191/449) of patients with SBP >140, including 63.5% (94/148) with SBP >160, were prescribed initial dual-agent therapy, an absolute increase of 18.5 percentage points (95% CI: 15.6 to 21.4; 66.7% relative increase) and 34.1 percentage points (95% CI: 29.1 to 39.1; 116.0% relative increase), respectively. SPCs were used in 28.0% (126/449) of patients with SBP >140 and 42.5% (63/148) with SBP >160, reflecting an absolute increase of 15.6 percentage points (95% CI: 13.1 to 18.1; 125.8% relative increase) and 28.5 percentage points (95% CI: 23.9 to 33.2; 203.6% relative increase), respectively ( Figure 2 ). All comparisons were statistically significant (p < 0.001). Conclusions: Dual-agent and SPC use as initial antihypertensive therapy significantly increased post-intervention. Patient reluctance toward dual-agent therapy emerged as a key barrier, highlighting the need for patient engagement and education. In conclusion, a systems-level QI initiative tailored to PCPs can improve alignment of HTN treatment with guidelines.