Use of continuous quality improvement to identify barriers in the management of hypertension.

We have made great strides in understanding the pathophysiology and medical management of hypertension, yet barriers to effective blood pressure control remain. The process of identifying the barriers within the health care system may be as important as the barriers themselves. Our primary purpose was to apply the widely accepted tool, Continuous Quality Improvement (CQI), to identify barriers to the management of hypertension. We wanted to identify the most important factors and (or) persons in effective blood pressure control and to compare costs, satisfaction, and blood pressure control among subgroups of patients to identify those most likely to benefit from interventions. We recruited patients with essential hypertension who came to a university-based clinic staffed by family physicians and residents; 181 patients with hypertension were identified and asked at the time of their visit to complete a questionnaire relating to the management of their blood pressure. Twenty-five physicians and 8 medical assistants were also asked to complete a similar questionnaire regarding their perceptions of barriers to blood pressure management. All other information came from the patients' medical records. Blood pressure control was based on a reading taken on the date the questionnaire was completed. Student's t test was used to determine if statistically significant differences existed in blood pressure control, patient satisfaction, and total costs for certain subgroups; regression analysis was used to determine correlations. We had completed questionnaires from 91 patients, 89 physicians, and 79 staff. The physicians and staff were of course involved; however, we found that the patients' gestalt was extremely important in blood pressure control. Our patients perceived that lifestyle modifications such as exercise and weight loss were the greatest barrier to better blood pressure control. The cost of certain antihypertensive drugs was an obstacle for some patients. African Americans had poorer blood pressure control, and their satisfaction of care was significantly lower than that of other races. Our patients taught us that the 2 major barriers to blood pressure control were changes in lifestyle and reducing the cost of medications. We also found that our African American patients showed the poorest blood pressure control and the greatest dissatisfaction with their care. We surmise that the greatest benefit of any intervention would be expected in this population. We demonstrated that CQI can be used to identify barriers to hypertension management and subgroups of patients likely to benefit from interventions.