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70 Barriers to management of hypertensionORIGINAL PAPER

Journal of Health Care for the Poor and Underserved 17 (2006): 7085.

SANDY COOKis a Senior Education Specialist at the Chicago Diabetes Research and Training Center

and is Associate Dean for Curricular Affairs at the University of Chicagos Pritzker School of Medicine.

She can be reached at [email protected]. Dr. Cook andMELINDA DRUM, ANNE KIRCHHOFF,

LEI JIN, JESSICA LEVIE, andMARSHALL CHINare all affiliated with the Dept. of Medicine and

Health Studies, or Diabetes Research and Training Center at the University of Chicago. At the time of the

studyJAMES HARRISONwas affiliated with the North Woods Community Health Center in Minong,Wisconsin; andSUSAN LIPPOLDwas affiliated with the Health Resources And Services Administration

in Chicago. CYNTHIA SCHAEFERis affiliated with the University Of Evansville in Evansville, Indiana.

Dr. Harrison is currently with South Lane Medical Group, in Cottage Grove, Oregon and Dr. Lippold is

currently with the Centers for Disease Control City of Chicago Tuberculosis Program.

Providers Assessment of Barriers to EffectiveManagement of Hypertension and Hyperlipidemiain Community Health Centers

Sandy Cook PhD

Melinda L. Drum PhD

Anne C. Kirchhoff MPH

Lei Jin PhD

Jessica Levie JD, MPH

James F. Harrison MD

Susan A. Lippold MD, MPH

Cynthia T. Schaefer RN, CS

Marshall H. Chin MD, MPH

Abstract: We explored 251 providers (47% licensed practical nurses, 27% registered nurses,

10% physicians, 10% physician assistants, 6% other) perceptions of barriers to effective

management of hypertension and hyperlipidemia from 72 Midwest community health centers

(CHCs). Optimal care for these diseases is difficult in any setting; little is known about thespecific barriers CHCs face. Community health centers often have a multidisciplinary team

that participates in patient care. Current models of quality improvement and chronic care

management require virtually all CHC providers to know clinical guidelines. Providers in this

study generally chose hypertension and hyperlipidemia target levels that met or were more

stringent than national guidelines, but lacked confidence to address behavioral change and

reported obstacles to modifying patient lifestyle. Community health centers should strengthen

providers skills in facilitating lifestyle change. Improving quality of care requires supporting

providers efforts to take patients psychosocial and financial challenges into account, and

revised policies to eliminate financial and cultural barriers to care.

Key words: Barriers to management, community health centers, hypertension, hyperlipidemia,guidelines.


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71Cook, Drum, Kirchhoff, Jin, Levie, Harrison, Lippold, Schaefer, and Chin

Hypertension and hyperlipidemia are highly prevalent among Americans.14

These conditions are routinely under-detected and either untreated or poorlycontrolled, especially among vulnerable populations, such as African Americansand those of low socioeconomic status.515 In the United States, over 30% of chronic

disease deaths come from heart disease. 3 Managing risk factors such as hypertensionand hyperlipidemia can help to reduce the development of heart disease and othercomplications.

Community health centers (CHCs) offer essential primary health care servicesto vulnerable populations living in rural and urban medically underservedcommunities16 and are fundamental to reducing health disparities between membersof these communities and the general population.17 Health centers often provide carethrough a multidisciplinary team, where providers must know clinical guidelines toeffectively participate in treatment. For example, in many centers, nurses develop self-

management goals for patients and assist primary care providers in the assessmentand evaluation of patients. Also, CHCs are increasingly focused on improving qualityof care through national efforts such as the Bureau of Primary Health Cares HealthDisparities Collaborative, which aims to eliminate health disparities and change theway care is delivered. One fundamental piece of the Collaborative model is providerknowledge of clinical guidelines as a part of developing a prepared, proactivepractice team [p. 1777],18 where nurses and other clinical staff play integral rolesin education and self-management support of patients.

With the focus on a team approach to care at CHCs, enhancing quality of careand health outcomes for patients at these centers requires intimate knowledge of thepatient, provider, and system level factors that affect the provision of services. Giventhe prevalence and morbidity of hypertension and hyperlipidemia, understandingthe barriers to providing optimal services for these conditions is vital to improvehealth outcomes for CHC patients.

Studies conducted in various settings and populations describe specific barriers toeffective hypertension and hyperlipidemia care. Barriers to hypertension care includeproviders non-adherence to recommended treatment guidelines and willingness toaccept an elevated blood pressure level,19,20 as well as specific patient-related barrierssuch as social, economic and lifestyle impediments.21, 22 For hyperlipidemia, physician

specialty and physician and patient demographics are related to underuse of lipid-reducing therapies.9,23,24 Hypertension and hyperlipidemia treatment barriers forpatients at CHCs are little explored. Therefore, we sought to identify barriers tothe delivery of high quality hypertension and hyperlipidemia care within the CHCsetting, ultimately to help CHCs develop interventions to improve care.

Methods

Study population. Due to themultidisciplinary team approach to care at CHCs,we surveyed a range of providers (licensed practical nurses, registered nurses, nurse

practitioners, physicians, physician assistants, and others) who have responsibilityfor the care of patients with hypertension and hyperlipidemia at federally-fundedCHCs associated with the MidWest Clinicians Network (MWCN). The MWCN is anonprofit corporation consisting of individual providers, community health centers,


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72 Barriers to management of hypertension

primary care associations, and other partners in 10 Midwestern states, coordinated bythe Michigan Primary Care Association and open to all CHC clinical providers withinthose states. We invited the 145 federally funded CHCs who were members of thenetwork in 2000 to provide a list of names of all providers who worked with patients

with hypertension and hyperlipidemia. Ninety-four centers (65%) returned lists ofnames, and surveys were sent to 84 (58%) centers. The study population consisted ofthe 758 providers whose addresses were accurate at the time the survey was mailed.The University of Chicago Institutional Review Board approved the study.

Survey development. The collaborative team of investigators from the MWCN,the Bureau of Primary Health Care, and the University of Chicago developed a76-question survey to address potential major barriers to providing optimal carewithin the key barrier domains listed below. This survey was based on our earlierprovider survey of the barriers to diabetes care in CHCs,25 as well as input from

CHC providers during an annual meeting of the MWCN. During that meeting,interviews with providers working at CHCs identified the following types of barriersto quality improvement:

Provider barriers: Lack of tracking and patient follow-up, lack of understandingof guidelines and the literature, controversy over guideline recommendations,lack of understanding of patient needs, and lack of training in facilitatingbehavioral change in patients;

Patient barriers: Lack of adherence to referrals, asymptomatic nature of thediseases, linguistic and cultural difficulties, psychosocial challenges blunting

efforts to adhere, lack of patients acceptance of disease, and difficulty of lifestylechanges;

Practice/system barriers: Lack of multidisciplinary cooperation, documentationburdens, difficulty educating patients at the right educational level, anddifficulty coordinating care with hospital.

In further discussions, members of the MWCN Research Committee recognizedthat economic and financial barriers, such as the expense of comprehensive care(including medications and diagnostic tests), inadequate reimbursement foreducational services, insufficient time for providers to coordinate staffing, and lack

of transportation, also have an impact on the practice of certain processes of care.Survey format.The first portion of the survey asked providers to indicate their

blood pressure and cholesterol goals for patients with varying cardiovascular riskfactors. Providers were then queried about barriers to care through Likert-scaleitems with 5 response options (1=strongly disagree to 5=strongly agree). To facilitateresponses, questions were grouped by content area: Medical Visits, Medications,Management, Lifestyle Factors (including diet, weight management, exercise,smoking cessation), and General Barriers to Care.

Additional questions elicited responses from providers on the frequency withwhich certain psychosocial issues (such as competing health, environmental, financial,and cultural needs) affected their patients abilities to manage their hypertensionand hyperlipidemia (Likert-scale: 1=never,5 = all the time).

Survey distribution. The 76 question survey was mailed to the 758 providerswith up to 2 follow-up mailings for non-respondents. After the second follow-up


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mailing, a reduced version of the survey with a subset of 18 key questions was mailedto providers who had not yet responded.

Statistical methods. Responses to survey items eliciting provider blood pressureand cholesterol goals for patients with different risk factor levels were classified

according to their agreement with the Sixth Report of the Joint National Committeeof Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNCVI)26 and Third Report of the National Cholesterol Education Program (NCEP)27Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterolin Adults (Adult Treatment Panel III) guidelines. While NCEP II guidelines28 werein force at the time of the initial mailing, NCEP III guidelines, which were releasedmidway through the collection of the surveys, were the ones used to measure theperformance rates. The only difference between NCEP II and NCEP III relevant tothis survey is that presence of diabetes as a comorbidity led to a target LDL of 130

mg/dL in NCEP II versus 100 mg/dL for NCEP III.27

Rates of agreement of bloodpressure and lipid goals with guideline recommendations were calculated with 95%confidence intervals. Rates are reported both for goals that were at or below theguidelines and for goals that were in exact agreement with the guidelines.

Responses to survey items assessing barriers to optimal care were dichotomizedas agree/ strongly agreeversus lower ratings due to the discreteness of the Likertresponse scale (1 = strongly disagree, 5 = strongly agree) and the typical skewnessof responses. Summary scales were constructed as averages of items belonging to10 specific survey domains (Table 1).

Reliability of summary scales was assessed using Cronbachs alpha (range: .59.95).The summary scales were then dichotomized to correspond to the original Likertscale, using 3.5 as the cutpoint between agree/strongly agreeand lower ratings. Ratesof agreement were calculated with 95% confidence intervals, and the effect of urbanversus rural location on rates of agreement was tested. Differences in responses toa limited number of related items, such as importance of medical versus lifestylemanagement, were also tested.

All analyses incorporated the hierarchical structure of the data arising fromnesting of providers within health centers by utilizing GEE (generalized estimatingequation) linear and logistic regression29 for continuous and dichotomous responses,

respectively. Rates of agreement were estimated by regression on intercept only;urban location was then added as a covariate to test the effect of urban versus rurallocation on the response. The association between related responses was evaluatedby regressing the first response on the second. When clustering is not present, theGEE models used are equivalent to ordinary linear and logistic models. In particular,regression on intercept only yields the usual point estimates and confidence intervalsfor means and proportions.

Results

Survey response and respondents. We received 251 (33%) surveys from 72 (89%)centers (219 full form, 32 reduced form). Forty-seven percent of respondents werelicensed practical nurses; 27% were registered nurses; 10% were physicians, and10% were physician assistants. The remaining 6% were administrators, dietitians,health educators, and other health care professionals. The respondents with clinical


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responsibilities reported a mean (sd) of 37(11) hours per week at their clinics and32(13) hours in direct patient care. On average, they cared for 34(29) hypertensionand 29(26) hyperlipidemia patients per week. There were 139 respondents from 40urban health centers and 112 respondents from 32 rural health centers.

Provider roles and barriers. Knowledge of treatment guidelines. A large majorityof respondents reported blood pressure and cholesterol goals that either met or weremore stringent than the guidelines for each clinical scenario (Table 2). The lowestrates of respondent agreement were for the 130/85 mm Hg blood pressure goal forpatients with hypertension and diabetes, and the 100 mg/dL LDL goal for patientswith hyperlipidemia and diabetes. However, almost all respondents matched or weremore stringent than the less strict NCEP II LDL goal of 130 mg/dL that was in effectat the time of the first mailing of the survey. A large proportion of providers reportedmore stringent goals than set by the guidelines for three scenarios (blood pressureamong hypertensive patients, LDL cholesterol for patients with hyperlipidemia, LDLcholesterol for patients with two cardiovascular risk factors) so that exact agreementin these cases was low.

Medical management and management behaviors. Most providers agreed that they

were confident in their knowledge of medical management for both hypertensionand hyperlipidemia (Table 3). Similarly, most providers agreed on the importanceof lifestyle modification and medical management (regular medical visits, takingmedications, and reporting side effects) (Table 3, Figure 1). There were no significantdifferences between urban and rural respondents in these areas.

a When to prescribe medications, which medications to prescribe, complications of medications,appropriate diagnostic testsb Regular medical visits, taking medications as prescribed, reporting side effectsc Diet, exercise, weight management, smoking cessationdRegular medical visits, taking medications as prescribed, taking medications in absence of symptoms,reporting side effectse How to take medications, side effects of medications, barriers to adherence to medical regimen

Table 1.

BARRIERS SUMMARY SCALES

Summary Scale Numberof items

Confidence in knowledge of medical management of hypertension. 4a

Confidence in knowledge of medical management of hyperlipidemia. 4a

Importance of medical management provider rating. 3b

Importance of lifestyle modification provider rating. 4c

Importance of medical management provider rating of patient perception. 4d

Importance of lifestyle modification provider rating of patient perception 4c

Responsibility for teaching medical management. 3e

Responsibility for teaching lifestyle change. 4c

Confidence in ability to teach lifestyle change. 4c

Confidence in ability to change patients lifestyle behavior. 4c


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Instruction of patients. The majority of providers agreed that it was theirresponsibility to teach patients lifestyle modification and medical management,including how to identify barriers to adherence (Table 3, Figure 2). Agreementwith responsibility for teaching medical management was significantly higher thanwith responsibility for teaching lifestyle change (p


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important for managing hypertension and hyperlipidemia (Table 3, Figure 1). Fewer

than half of providers agreed that patients consider medical management important,and even fewer agreed that patients consider lifestyle modification important. Inaddition, providers at urban health centers were less likely than those at rural locationsto agree that their patients consider taking medications important (Table 4).

Table 3.

PERCENT OF RESPONDENTS WHO AGREED ON MEDICALMANAGEMENT AND LIFESTYLE MODIFICATION FOR PATIENTS

WITH HYPERTENSION AND HYPERLIPIDEMIAa

Provider Agreement

Percent (95% C.I.)

Medical management Confident in knowledge of medical

management of hypertension. 81 (.73,.87)

Confident in knowledge of medical

management of hyperlipidemia. 82 (.75,.88)Importance of patient management behaviors

Medical management 96 (.93,.98)

Lifestyle modification 95 (.92,.97)

Instruction of patients

Responsibility to teach medical management 93 (.89,.96)

Responsibility to teach lifestyle modification 82 (.76,.86)

Confident in ability to teach lifestyle change 59 (.52,.65)

-if agreed on responsibility to teach 73 (.65,.79)

Confident in ability to effect lifestyle change 35 (.29,.42)

-if confident in ability to teach 55 (.48,.63)

Patient barriers Importance to patients

-medical management 41 (.34,.47)

-lifestyle modification 21 (.17,.27)

Adherence difficulty

-medication adherence 28 (.22,.35)

-lifestyle modification 75 (.69,.81)

Provider barriers (practice/system level)

Lack of time to teach medical adherence 72 (.66,.78) Lack of time to teach lifestyle modification 59 (.52,.65)

-if agreed to responsibility to teach 62 (.55,.69)

Adequate resources for lifestyle instruction 23 (.17,.31)

-if agreed to responsibility to teach 22 (.16,.31)

a Barriers summary scales. Items contributing to the scales are described in Table 1. Responses toindividual items comprising the scales are summarized in Figures 14.


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Figure 1. Providers Beliefs in Importance of Medical Management and Lifestyle Modification

Behaviors.

Figure 2. Providers Responsibility, Confidence, and Resources for Teaching Lifestyle

Modification and Medication Usage.


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Difficulty of adherence. A large majority of providers indicated that the complexityor challenges of the behavioral aspects of effective management created barriers fortheir patients (Table 3, Figure 3). Taking medication as prescribed was not judged tobe as complex or difficult as lifestyle modification. A substantial minority of providersreported that disability, lack of time, and safety concerns hindered patients effortsto exercise. Urban providers were more likely than rural providers to consider safetyand disability to be barriers to exercise for their patients (Table 4).

Financial barriers. Many providers reported that financial problems, such as lack

of employment or health insurance, frequently affect their patients ability to managetheir hypertension and hyperlipidemia effectively. More specifically, a majorityagreed that their non-Medicaid patients could not afford their medications. Fewerproviders considered costs of medical visits, special diet, weight management, or

Table 4.

DIFFERENCES BETWEEN URBAN AND RURAL RESPONDENTSIN LEVEL OF AGREEMENT ON MEDICAL MANAGEMENT AND

LIFESTYLE MODIFICATION ISSUES FOR PATIENTS WITHHYPERTENSION AND HYPERLIPIDEMIAA

Provider agreement: Urban Rural Odds Ratio

(%) (%) (95% CI) P valuea

a Results are presented for responses that differed between urban and rural providers at significancelevel p


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exercise to be obstacles (Figure 3). Providers at urban health centers were more likelythan those at rural locations to consider costs of lifestyle modification problematicfor their patients (Table 4).

Psychosocial barriers. A majority of providers reported that psychosocialfactors considerably affect their patients ability to manage their hypertension andhyperlipidemia successfully (Figure 4). Personal and family matters (e.g., lack of familysupport, overwhelming family responsibilities, domestic violence) were considered

problematic by the largest proportion of providers. A majority of providers alsoconsidered the impact to be substantial for psychological factors (e.g., depression,limited intellectual functioning, substance abuse), competing health conditions(e.g., diabetes, asthma), environmental factors (e.g., limited transportation, limitedaccess to healthier foods, neighborhood violence), and cultural factors (e.g., attitudesabout medication, dietary practices, religious beliefs, ethnic and family customs).More urban respondents reported that psychosocial barriers affected their patientsability to manage their hypertension or hyperlipidemia (Table 4), with no significantdifference between urban and rural respondents.

Practice/system barriers. Time and resources. A large majority of providers agreedthat finding time to teach about the importance of adherence to the medical regimenwas a barrier to effective care; over half reported that lack of time was a barrier toinstruction on lifestyle modification, while fewer than 25% agreed that resourcesfor instruction in their health center were adequate (Table 3).

Figure 3. Providers Perceptions of Patient Barriers to Management of Hypertension and

Hyperlipidemia.


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Discussion

This survey identified key barriers and systemic impediments that health centerproviders face while caring for their patients. Prior studies suggest several factors thatresult in lower adherence to hypertension and hyperlipidemia treatment guidelinesamong generalist physicians. These include complex and changing clinical guidelines,a lack of physician knowledge of these guidelines, and a lack of compliance.3033 Unlike

previous studies, ours found that the CHC providers generally selected target bloodpressure and lipid levels that were at or below recommended clinical guidelines.Certain providers, such as the licensed practical nurses (LPNs) who provided thelargest proportion of our responses, traditionally may not be expected to knowclinical guidelines, although, with the multidisciplinary nature of care at CHCs andthe increasing focus on quality improvement, staff at all levels are being educatedabout them. In fact, nurses and medical assistants often work with patients to setself-management goals; and in many centers, these types of providers are empoweredto remind primary care providers of specific labs and referrals needed to adhere toclinical guidelines. Therefore, adequate guideline knowledge by all providers is partof the commitment CHCs have made to providing comprehensive care.

We did find that for some of the clinical scenarios described on the survey,agreement was low, which may indicate a remaining knowledge gap among some

Figure 4. Providers Perceptions of Impact of Psychosocial Factors on Management ofHypertension and Hyperlipidemia.


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provider types. Specifically, relating to the blood pressure goal of 130/85 mm Hgfor patients with hypertension and diabetes (or, even more stringently, 130/80 mmHg, as currently recommended by the American Diabetes Association)34 and for therevised LDL goal of 100 mg/dL for patients with hyperlipidemia and diabetes. This

discrepancy with the LDL guideline is difficult to interpret due to the change in theNCEP guidelines over the course of the study.

The belief of providers that their patients do not think certain components ofhypertension and hyperlipidemia care are important may affect the way they treatand communicate with their patients. Effective patient-provider communicationand agreement about treatment are associated with improved treatment adherence,self-management skills, and enhanced health outcomes.35,36 Providers with pessimisticbeliefs of their patients attitudes may inadvertently convey lower expectationsto their patients and fail to involve patients in developing self-treatment goals.

If patients believe medication or lifestyle adherence is important, but see thesefacets of care disregarded by their providers, this may lead to distrust or decreasedcommunication. Since patients who do not trust or have good communication withtheir providers are less likely to feel they are receiving services they need,37 gaininga better understanding of why providers think their patients often do not adhereto their hypertension and hyperlipidemia treatment plans is essential to improvingcare. While it is difficult to determine whether our providers perceptions representan over- or underestimation of patients actual beliefs, it is critical to understandwhether the providers assessments truly reflect their patients beliefs and, if not,why the gap exists and what effect it may have on effective communication andhealth care outcomes of their patients. Discovering why urban and rural providersdiffer regarding patients assessment of medication importance would contributeto understanding this issue.

Providers in this survey considered their responsibility for teaching medicalcompliance greater than their responsibility for teaching lifestyle change, whichalso may have an effect on patient adherence to diet, weight management, smokingcessation, and exercise treatment recommendations. Additionally, few providers wereconfident in their ability to change patients behaviors. Other studies cite a lack ofpatient adherence to medication regimens as a major barrier to good cardiovascular

care.3841 Providers need the skills to promote both medical adherence and lifestylechange as necessary actions for hypertension and hyperlipidemia treatment in theirpatients.

In a recent study of a physicians group, time was not deemed an important barrierto making needed changes in hypertension medication.19 In CHCs, however, time andother system barriers may be more salient than in private health care groups. Providersin our study reported insufficient time to educate patients, inadequate resources topromote lifestyle behavior change, and negative effects of patients financial statuson hypertension and hyperlipidemia management. Research examining how CHCsorganizational structure and the economic status of patients influence clinical careand outcomes is critical for the development of effective health care policies.

The 33% survey response rate, while reasonable for busy providers in resource-constrained situations, may limit the generalizability of our findings due to selection


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bias. In particular, providers knowledge of national guidelines for the care ofpatients with hypertension and hyperlipidemia may be overestimated, becauseresponding providers may be those who are more likely to stay apprised of currentrecommendations. The other major findings regarding the challenges of lifestyle

changes, resource constraints, financial problems, and psychosocial problems arelikely to be valid, as we found analogous results in the survey we performed of healthcenter providers regarding diabetes management with 72% response rate.25 Also,since guidelines are updated, we used the more stringent NCEP III hyperlipidemiaguidelines that were released during the study as the benchmark standard.42 Thischoice may partially counteract a selection bias of respondents who were aggressiveabout treating high cholesterol. Despite these possible limitations, our surveysupplies important information regarding the types of barriers impeding qualityimprovement efforts for cardiovascular care in CHCs.

In addition, we recommend further research on targeted interventions that gobeyond the mere dissemination of knowledge. These interventions must strive tochange behavior of both providers and patients and improve the organizationalsystems that affect management of chronic diseases.

Interventions that encourage patients to play a more active role in theirhypertension and hyperlipidemia care, accompanied by programs that increaseproviders confidence in their ability to help bring about behavior change in theirpatients, may be helpful. In addition, as our providers believed financial andpsychosocial barriers impaired patients ability to manage their hypertension andhyperlipidemia, programs to assist providers, health centers, and patients addressthose issues may also improve patient outcomes. Quality improvement initiativescan only succeed if we understand the circumstances that give rise to barriers.

Lastly, improving hypertension and hyperlipidemia care at the CHC populationlevel requires a comprehensive review of health care policies and reimbursement, aswell as consideration of the CHC organizational structure. One recent interventionthat recognizes the role of the larger organizational structure in changing andimproving the clinic delivery system is the BPHCs Health Disparities Collaborative.Using the Chronic Care Model and a system of rapid change (Plan-Do-Study-Act(PDSA)) cycles for continuous quality improvement, the BPHC has helped CHCs

examine broad systems issues and improve the quality of care.43,44 One lesson theyhave learned is that while it is possible to make systemic changes,45 it is challengingto sustain them. Future research must focus not only on acknowledging andunderstanding patient, provider, and system level barriers to care, but on finding waysto incorporate long-term solutions to these barriers into the culture and financialenvironment of community health centers.

Acknowledgments

This project was supported by the Bureau of Primary Health Care / Agency for

Healthcare Research and Quality (6 H68 CS 0013515 S5 R5), and the NationalInstitute of Diabetes and Digestive and Kidney Diseases Diabetes Research andTraining Center (P60 DK20595). Dr. Chin was a Robert Wood Johnson FoundationGeneralist Physician Faculty Scholar.


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This paper was presented in part at the Midwest Society of General InternalMedicine annual meeting, September 28, 2002, Chicago, Illinois.

Notes

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