Factors Associated with Treatment Intensification for Uncontrolled Hypertension in a US Health System.

Abstract

Therapeutic inertia is a key barrier to blood pressure (BP) control. To identify demographic, clinical, and health system factors associated with treatment intensification for uncontrolled hypertension including in-person medical office versus team-based BP clinic encounters. This mixed-methods study included a quantitative analysis of electronic health records and 11 semi-structured provider interviews from Kaiser Permanente Southern California (KPSC). This study included KPSC adults with hypertension and uncontrolled BP (≥ 140/ ≥ 90 mm Hg) during office encounters in 2018, followed for 6 months. Treatment intensification defined as increasing dose or adding a new class of antihypertensive medications, and 6-month BP reduction associated with treatment intensification. Multivariable regression analyses were used to identify factors associated with treatment intensification. Themes around barriers and facilitators of treatment intensification were developed from the provider interviews. Among 221,519 patients with uncontrolled BP, 29% received an increased dose or added medications. Mean (SD) 6-month systolic BP reductions were 16.6 (14.3) mm Hg and 11.7 (13.5) mm Hg for those with treatment intensification versus not (p < 0.01). Older age (OR for age ≥ 76 vs 18-55 years = 0.68; 95% CI 0.65, 0.71) and having diabetes (OR = 0.86; 95% CI 0.84, 0.88) were associated with lower odds of treatment intensification; while team-based BP clinic encounters were associated with higher odds of treatment intensification (OR = 1.23; 95% CI 1.20, 1.27). Provider interviews showed concerns about side effects, medication nonadherence, and shared decision-making are key factors in decisions to intensify therapy. Less than one-third of patients with uncontrolled BP received increased hypertension medication doses, with more frequent intensifications in team-based BP clinics. Targeted interventions to address the identified barriers are needed to improve BP control.