title: Identifying barriers to hypertension guideline adherence using clinician feedback at the point of care.
abstract: Factors contributing to low adherence to clinical guidelines by clinicians are not well understood. The user interface of ATHENA-HTN, a guideline-based decision support system (DSS) for hypertension, presents a novel opportunity to collect clinician feedback on recommendations displayed at the point of care. We analyzed feedback from 46 clinicians who received ATHENA advisories as part of a 15-month randomized trial to identify potential reasons clinicians may not intensify hypertension therapy when it is recommended. Among the 368 visits for which feedback was provided, clinicians commonly reported they did not follow recommendations because: recorded blood pressure was not representative of the patient's typical blood pressure; hypertension was not a clinical priority for the visit; or patients were nonadherent to medications. For many visits, current quality-assurance algorithms may incorrectly identify clinically appropriate decisions as guideline nonadherent due to incomplete capture of relevant information. We present recommendations for how automated DSSs may help identify "apparent" barriers and better target decision support.
authors.affiliation: GRECC, VA Palo Alto Health Care System, Palo Alto, CA, USA.
authors.forename: N D
authors.initials: ND
authors.lastname: Lin
authors.forename: S B
authors.initials: SB
authors.lastname: Martins
authors.forename: A S
authors.initials: AS
authors.lastname: Chan
authors.forename: R W
authors.initials: RW
authors.lastname: Coleman
authors.forename: H B
authors.initials: HB
authors.lastname: Bosworth
authors.forename: E Z
authors.initials: EZ
authors.lastname: Oddone
authors.forename: R D
authors.initials: RD
authors.lastname: Shankar
authors.forename: M A
authors.initials: MA
authors.lastname: Musen
authors.forename: B B
authors.initials: BB
authors.lastname: Hoffman
authors.forename: M K
authors.initials: MK
authors.lastname: Goldstein
mesh_terms: D000368:Aged; D020000:Decision Support Systems, Clinical; D005246:Feedback; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D008297:Male; D010821:Physicians, Family; D019095:Point-of-Care Systems; D017410:Practice Guidelines as Topic; D017010:Reminder Systems; D013813:Therapy, Computer-Assisted; D014584:User-Computer Interface