Physician-related barriers to the effective management of uncontrolled hypertension.

BACKGROUND: Primary care physicians may not be aggressive enough with the management of hypertension. The purpose of this study was to identify barriers to primary care physicians' willingness to increase the intensity of treatment among patients with uncontrolled hypertension.
METHODS: Descriptive survey study. We sampled patient visits in a large midwestern health system to identify patients with uncontrolled hypertension. The treating primary care physicians were asked to complete a survey about the patient visit with a copy of the office notes attached to the survey (patient visits, n = 270; response rate, 86%).
RESULTS: Pharmacologic therapy was initiated or changed at only 38% of visits, despite documented hypertension for at least 6 months before the patients' most recent visit. The most frequently cited reason for no initiation or change in therapy was related to the primary care physicians being satisfied with the blood pressure (BP) value (satisfactory BP response, 30%; satisfactory diastolic BP response, 16%; only borderline hypertension, 10%). At 93% of these visits, systolic BP values were 140 mm Hg or higher, which is above the cut point recommended by Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, and 35% were 150 mm Hg or higher. On average, physicians reported that 150 mm Hg was the lowest systolic BP at which they would recommend pharmacologic treatment to patients, compared with 91 mm Hg for diastolic BP.
CONCLUSIONS: Our findings suggest that an important reason why physicians do not treat hypertension more aggressively is that they are willing to accept an elevated systolic BP in their patients. This has an important impact on public health because of the positive association between systolic BP and cardiovascular disease.