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 2 nd 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. Key Points Question What are the plausible scenarios and influencing factors contributing to clinician non-adherence to the guidelines for hypertension management? Findings In this qualitative study, we developed three domains of suboptimal adherence: clinician-related scenarios, patient-related scenarios, and clinical complexity-related scenarios; and identified several plausible influencing factors, including a lack of clear protocols and processes to implement guidelines, infrastructure limitations, and clinicians’ lack of autonomy and authority, excessive workload, time constraints, clinician belief or perception. Meaning This study introduces a taxonomy poised to inform targeted interventions, thereby enhancing guideline adherence and elevating care quality for severe hypertension.