patient case study hypertension

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Patient Case Presentation

Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%.  Glucose  180 mg/dL (fasting).  FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.

Past medical history

Diagnosed with diabetes (type 2) at 32 years old

Overweight, BMI of 31

Had a cholecystomy at 38 years old

Diagnosed with dyslipidemia at 32 years old

Past family history

Mother alive, diagnosed diabetic at 42 years old 

Father alive with Hypertension diagnosed at 55 years old

Brother alive and well at 45 years old

Sister alive and obese at 34 years old 

Pertinent social history

Social drinker on occasion

Smokes a pack of cigarettes per day

Works full time as an IT technician and is in graduate school

• Previous Article
• Next Article

Presentation

Clinical pearls, case study: treating hypertension in patients with diabetes.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Cite Icon Cite
• Get Permissions

Evan M. Benjamin; Case Study: Treating Hypertension in Patients With Diabetes. Clin Diabetes 1 July 2004; 22 (3): 137–138. https://doi.org/10.2337/diaclin.22.3.137

Download citation file:

• Ris (Zotero)
• Reference Manager

L.N. is a 49-year-old white woman with a history of type 2 diabetes,obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side,with her weight fluctuating between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A 1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

What are the effects of controlling BP in people with diabetes?

What is the target BP for patients with diabetes and hypertension?

Which antihypertensive agents are recommended for patients with diabetes?

Diabetes mellitus is a major risk factor for cardiovascular disease (CVD). Approximately two-thirds of people with diabetes die from complications of CVD. Nearly half of middle-aged people with diabetes have evidence of coronary artery disease (CAD), compared with only one-fourth of people without diabetes in similar populations.

Patients with diabetes are prone to a number of cardiovascular risk factors beyond hyperglycemia. These risk factors, including hypertension,dyslipidemia, and a sedentary lifestyle, are particularly prevalent among patients with diabetes. To reduce the mortality and morbidity from CVD among patients with diabetes, aggressive treatment of glycemic control as well as other cardiovascular risk factors must be initiated.

Studies that have compared antihypertensive treatment in patients with diabetes versus placebo have shown reduced cardiovascular events. The United Kingdom Prospective Diabetes Study (UKPDS), which followed patients with diabetes for an average of 8.5 years, found that patients with tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg) had lower rates of myocardial infarction (MI), stroke, and peripheral vascular events. In the UKPDS, each 10-mmHg decrease in mean systolic BP was associated with a 12% reduction in risk for any complication related to diabetes, a 15% reduction for death related to diabetes, and an 11% reduction for MI. Another trial followed patients for 2 years and compared calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors,with or without hydrochlorothiazide against placebo and found a significant reduction in acute MI, congestive heart failure, and sudden cardiac death in the intervention group compared to placebo.

The Hypertension Optimal Treatment (HOT) trial has shown that patients assigned to lower BP targets have improved outcomes. In the HOT trial,patients who achieved a diastolic BP of < 80 mmHg benefited the most in terms of reduction of cardiovascular events. Other epidemiological studies have shown that BPs > 120/70 mmHg are associated with increased cardiovascular morbidity and mortality in people with diabetes. The American Diabetes Association has recommended a target BP goal of < 130/80 mmHg. Studies have shown that there is no lower threshold value for BP and that the risk of morbidity and mortality will continue to decrease well into the normal range.

Many classes of drugs have been used in numerous trials to treat patients with hypertension. All classes of drugs have been shown to be superior to placebo in terms of reducing morbidity and mortality. Often, numerous agents(three or more) are needed to achieve specific target levels of BP. Use of almost any drug therapy to reduce hypertension in patients with diabetes has been shown to be effective in decreasing cardiovascular risk. Keeping in mind that numerous agents are often required to achieve the target level of BP control, recommending specific agents becomes a not-so-simple task. The literature continues to evolve, and individual patient conditions and preferences also must come into play.

While lowering BP by any means will help to reduce cardiovascular morbidity, there is evidence that may help guide the selection of an antihypertensive regimen. The UKPDS showed no significant differences in outcomes for treatment for hypertension using an ACE inhibitor or aβ-blocker. In addition, both ACE inhibitors and angiotensin II receptor blockers (ARBs) have been shown to slow the development and progression of diabetic nephropathy. In the Heart Outcomes Prevention Evaluation (HOPE)trial, ACE inhibitors were found to have a favorable effect in reducing cardiovascular morbidity and mortality, whereas recent trials have shown a renal protective benefit from both ACE inhibitors and ARBs. ACE inhibitors andβ-blockers seem to be better than dihydropyridine calcium-channel blockers to reduce MI and heart failure. However, trials using dihydropyridine calcium-channel blockers in combination with ACE inhibitors andβ-blockers do not appear to show any increased morbidity or mortality in CVD, as has been implicated in the past for dihydropyridine calcium-channel blockers alone. Recently, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in high-risk hypertensive patients,including those with diabetes, demonstrated that chlorthalidone, a thiazide-type diuretic, was superior to an ACE inhibitor, lisinopril, in preventing one or more forms of CVD.

L.N. is a typical patient with obesity, diabetes, and hypertension. Her BP control can be improved. To achieve the target BP goal of < 130/80 mmHg, it may be necessary to maximize the dose of the ACE inhibitor and to add a second and perhaps even a third agent.

Diuretics have been shown to have synergistic effects with ACE inhibitors,and one could be added. Because L.N. has migraine headaches as well as diabetic nephropathy, it may be necessary to individualize her treatment. Adding a β-blocker to the ACE inhibitor will certainly help lower her BP and is associated with good evidence to reduce cardiovascular morbidity. Theβ-blocker may also help to reduce the burden caused by her migraine headaches. Because of the presence of microalbuminuria, the combination of ARBs and ACE inhibitors could also be considered to help reduce BP as well as retard the progression of diabetic nephropathy. Overall, more aggressive treatment to control L.N.'s hypertension will be necessary. Information obtained from recent trials and emerging new pharmacological agents now make it easier to achieve BP control targets.

Hypertension is a risk factor for cardiovascular complications of diabetes.

Clinical trials demonstrate that drug therapy versus placebo will reduce cardiovascular events when treating patients with hypertension and diabetes.

A target BP goal of < 130/80 mmHg is recommended.

Pharmacological therapy needs to be individualized to fit patients'needs.

ACE inhibitors, ARBs, diuretics, and β-blockers have all been documented to be effective pharmacological treatment.

Combinations of drugs are often necessary to achieve target levels of BP control.

ACE inhibitors and ARBs are agents best suited to retard progression of nephropathy.

Evan M. Benjamin, MD, FACP, is an assistant professor of medicine and Vice President of Healthcare Quality at Baystate Medical Center in Springfield, Mass.

Email alerts

• Online ISSN 1945-4953
• Print ISSN 0891-8929
• Diabetes Care
• Clinical Diabetes
• Diabetes Spectrum
• Standards of Medical Care in Diabetes
• Scientific Sessions Abstracts
• BMJ Open Diabetes Research & Care
• ShopDiabetes.org
• ADA Professional Books

Clinical Compendia

• Clinical Compendia Home
• Latest News
• DiabetesPro SmartBrief
• Special Collections
• DiabetesPro®
• Diabetes Food Hub™
• Insulin Affordability
• Know Diabetes By Heart™
• About the ADA
• Journal Policies
• For Reviewers
• Advertising in ADA Journals
• Reprints and Permission for Reuse
• Copyright Notice/Public Access Policy
• ADA Professional Membership
• ADA Member Directory
• Diabetes.org
• X (Twitter)
• Cookie Policy
• Accessibility
• Terms & Conditions
• Get Adobe Acrobat Reader
• © Copyright American Diabetes Association

This Feature Is Available To Subscribers Only

Sign In or Create an Account

• Search Menu
• Advance articles
• Editor's Choice
• Graphical Abstracts and Tidbit
• Author Guidelines
• Submission Site
• Open Access
• About American Journal of Hypertension
• Editorial Board
• Board of Directors
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• AJH Summer School
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Clinical management and treatment decisions, hypertension in black americans, pharmacologic treatment of hypertension in black americans.

• < Previous
• Article contents
• Figures & tables
• Supplementary Data

Suzanne Oparil, Case study, American Journal of Hypertension , Volume 11, Issue S8, November 1998, Pages 192S–194S, https://doi.org/10.1016/S0895-7061(98)00195-2

• Permissions Icon Permissions

Ms. C is a 42-year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease (CVD). In addition, both her maternal and paternal grandparents had CVD.

At physician visit one, Ms. C presented with complaints of headache and general weakness. She reported that she has been taking many medications for her hypertension in the past, but stopped taking them because of the side effects. She could not recall the names of the medications. Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. In addition, Ms. C admits that she has found it difficult to exercise, stop smoking, and change her eating habits. Findings from a complete history and physical assessment are unremarkable except for the presence of moderate obesity (5 ft 6 in., 150 lbs), minimal retinopathy, and a 25-year history of smoking approximately one pack of cigarettes per day. Initial laboratory data revealed serum sodium 138 mEq/L (135 to 147 mEq/L); potassium 3.4 mEq/L (3.5 to 5 mEq/L); blood urea nitrogen (BUN) 19 mg/dL (10 to 20 mg/dL); creatinine 0.9 mg/dL (0.35 to 0.93 mg/dL); calcium 9.8 mg/dL (8.8 to 10 mg/dL); total cholesterol 268 mg/dL (< 245 mg/dL); triglycerides 230 mg/dL (< 160 mg/dL); and fasting glucose 105 mg/dL (70 to 110 mg/dL). The patient refused a 24-h urine test.

Taking into account the past history of compliance irregularities and the need to take immediate action to lower this patient’s blood pressure, Ms. C’s pharmacologic regimen was changed to a trial of the angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; her HCTZ was discontinued. In addition, recommendations for smoking cessation, weight reduction, and diet modification were reviewed as recommended by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). 1

After a 3-month trial of this treatment plan with escalation of the enalapril dose to 20 mg/day, the patient’s blood pressure remained uncontrolled. The patient’s medical status was reviewed, without notation of significant changes, and her antihypertensive therapy was modified. The ACE inhibitor was discontinued, and the patient was started on the angiotensin-II receptor blocker (ARB) losartan, 50 mg/day.

After 2 months of therapy with the ARB the patient experienced a modest, yet encouraging, reduction in blood pressure (140/100 mm Hg). Serum electrolyte laboratory values were within normal limits, and the physical assessment remained unchanged. The treatment plan was to continue the ARB and reevaluate the patient in 1 month. At that time, if blood pressure control remained marginal, low-dose HCTZ (12.5 mg/day) was to be added to the regimen.

Hypertension remains a significant health problem in the United States (US) despite recent advances in antihypertensive therapy. The role of hypertension as a risk factor for cardiovascular morbidity and mortality is well established. 2–7 The age-adjusted prevalence of hypertension in non-Hispanic black Americans is approximately 40% higher than in non-Hispanic whites. 8 Black Americans have an earlier onset of hypertension and greater incidence of stage 3 hypertension than whites, thereby raising the risk for hypertension-related target organ damage. 1 , 8 For example, hypertensive black Americans have a 320% greater incidence of hypertension-related end-stage renal disease (ESRD), 80% higher stroke mortality rate, and 50% higher CVD mortality rate, compared with that of the general population. 1 , 9 In addition, aging is associated with increases in the prevalence and severity of hypertension. 8

Research findings suggest that risk factors for coronary heart disease (CHD) and stroke, particularly the role of blood pressure, may be different for black American and white individuals. 10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to that of nonblack American hypertensives. 13 , 14

Data also reveal differences between black American and white individuals in responsiveness to antihypertensive therapy. For instance, studies have shown that diuretics 15 , 16 and the calcium channel blocker diltiazem 16 , 17 are effective in lowering blood pressure in black American patients, whereas β-adrenergic receptor blockers and ACE inhibitors appear less effective. 15 , 16 In addition, recent studies indicate that ARB may also be effective in this patient population.

Angiotensin-II receptor blockers are a relatively new class of agents that are approved for the treatment of hypertension. Currently, four ARB have been approved by the US Food and Drug Administration (FDA): eprosartan, irbesartan, losartan, and valsartan. Recently, a 528-patient, 26-week study compared the efficacy of eprosartan (200 to 300 mg/twice daily) versus enalapril (5 to 20 mg/daily) in patients with essential hypertension (baseline sitting diastolic blood pressure [DBP] 95 to 114 mm Hg). After 3 to 5 weeks of placebo, patients were randomized to receive either eprosartan or enalapril. After 12 weeks of therapy within the titration phase, patients were supplemented with HCTZ as needed. In a prospectively defined subset analysis, black American patients in the eprosartan group (n = 21) achieved comparable reductions in DBP (−13.3 mm Hg with eprosartan; −12.4 mm Hg with enalapril) and greater reductions in systolic blood pressure (SBP) (−23.1 with eprosartan; −13.2 with enalapril), compared with black American patients in the enalapril group (n = 19) ( Fig. 1 ). 18 Additional trials enrolling more patients are clearly necessary, but this early experience with an ARB in black American patients is encouraging.

Efficacy of the angiotensin II receptor blocker eprosartan in black American with mild to moderate hypertension (baseline sitting DBP 95 to 114 mm Hg) in a 26-week study. Eprosartan, 200 to 300 mg twice daily (n = 21, solid bar), enalapril 5 to 20 mg daily (n = 19, diagonal bar). †10 of 21 eprosartan patients and seven of 19 enalapril patients also received HCTZ. Adapted from data in Levine: Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study, in Programs and abstracts from the 1st International Symposium on Angiotensin-II Antagonism, September 28–October 1, 1997, London, UK.

Approximately 30% of all deaths in hypertensive black American men and 20% of all deaths in hypertensive black American women are attributable to high blood pressure. Black Americans develop high blood pressure at an earlier age, and hypertension is more severe in every decade of life, compared with whites. As a result, black Americans have a 1.3 times greater rate of nonfatal stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times greater rate of heart disease deaths, and a 5 times greater rate of ESRD when compared with whites. 19 Therefore, there is a need for aggressive antihypertensive treatment in this group. Newer, better tolerated antihypertensive drugs, which have the advantages of fewer adverse effects combined with greater antihypertensive efficacy, may be of great benefit to this patient population.

1. Joint National Committee : The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med 1997 ; 24 157 : 2413 – 2446 .

Google Scholar

2. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg . JAMA 1967 ; 202 : 116 – 122 .

3. Veterans Administration Cooperative Study Group on Antihypertensive Agents : Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg . JAMA 1970 ; 213 : 1143 – 1152 .

4. Pooling Project Research Group : Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to the incidence of major coronary events: Final report of the pooling project . J Chronic Dis 1978 ; 31 : 201 – 306 .

5. Hypertension Detection and Follow-Up Program Cooperative Group : Five-year findings of the hypertension detection and follow-up program: I. Reduction in mortality of persons with high blood pressure, including mild hypertension . JAMA 1979 ; 242 : 2562 – 2577 .

6. Kannel WB , Dawber TR , McGee DL : Perspectives on systolic hypertension: The Framingham Study . Circulation 1980 ; 61 : 1179 – 1182 .

7. Hypertension Detection and Follow-Up Program Cooperative Group : The effect of treatment on mortality in “mild” hypertension: Results of the Hypertension Detection and Follow-Up Program . N Engl J Med 1982 ; 307 : 976 – 980 .

8. Burt VL , Whelton P , Roccella EJ et al.  : Prevalence of hypertension in the US adult population: Results from the third National Health and Nutrition Examination Survey, 1988–1991 . Hypertension 1995 ; 25 : 305 – 313 .

9. Klag MJ , Whelton PK , Randall BL et al.  : End-stage renal disease in African-American and white men: 16-year MRFIT findings . JAMA 1997 ; 277 : 1293 – 1298 .

10. Neaton JD , Kuller LH , Wentworth D et al.  : Total and cardiovascular mortality in relation to cigarette smoking, serum cholesterol concentration, and diastolic blood pressure among black and white males followed up for five years . Am Heart J 1984 ; 3 : 759 – 769 .

11. Gillum RF , Grant CT : Coronary heart disease in black populations II: Risk factors . Heart J 1982 ; 104 : 852 – 864 .

12. M’Buyamba-Kabangu JR , Amery A , Lijnen P : Differences between black and white persons in blood pressure and related biological variables . J Hum Hypertens 1994 ; 8 : 163 – 170 .

13. Hypertension Detection and Follow-up Program Cooperative Group : Five-year findings of the Hypertension Detection and Follow-up Program: mortality by race-sex and blood pressure level: a further analysis . J Community Health 1984 ; 9 : 314 – 327 .

14. Ooi WL , Budner NS , Cohen H et al.  : Impact of race on treatment response and cardiovascular disease among hypertensives . Hypertension 1989 ; 14 : 227 – 234 .

15. Weinberger MH : Racial differences in antihypertensive therapy: evidence and implications . Cardiovasc Drugs Ther 1990 ; 4 ( suppl 2 ): 379 – 392 .

16. Materson BJ , Reda DJ , Cushman WC et al.  : Single-drug therapy for hypertension in men: A comparison of six antihypertensive agents with placebo . N Engl J Med 1993 ; 328 : 914 – 921 .

17. Materson BJ , Reda DJ , Cushman WC for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents : Department of Veterans Affairs single-drug therapy of hypertension study: Revised figures and new data . Am J Hypertens 1995 ; 8 : 189 – 192 .

18. Levine B : Subgroup analysis of black hypertensive patients treated with eprosartan or enalapril: results of a 26-week study , in Programs and abstracts from the first International Symposium on Angiotensin-II Antagonism , September 28 – October 1 , 1997 , London, UK .

19. American Heart Association: 1997 Heart and Stroke Statistical Update . American Heart Association , Dallas , 1997 .

• hypertension
• blood pressure
• african american

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1941-7225
• Copyright © 2024 American Journal of Hypertension, Ltd.
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 6:  10 Real Cases on Hypertensive Emergency and Pericardial Disease: Diagnosis, Management, and Follow-Up

Niel Shah; Fareeha S. Alavi; Muhammad Saad

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Case review, case discussion.

• Clinical Symptoms
• Diagnostic Evaluation
• Full Chapter
• Supplementary Content

Case 1: Management of Hypertensive Encephalopathy

A 45-year-old man with a 2-month history of progressive headache presented to the emergency department with nausea, vomiting, visual disturbance, and confusion for 1 day. He denied fever, weakness, numbness, shortness of breath, and flulike symptoms. He had significant medical history of hypertension and was on a β-blocker in the past, but a year ago, he stopped taking medication due to an unspecified reason. The patient denied any history of tobacco smoking, alcoholism, and recreational drug use. The patient had a significant family history of hypertension in both his father and mother. Physical examination was unremarkable, and at the time of triage, his blood pressure (BP) was noted as 195/123 mm Hg, equal in both arms. The patient was promptly started on intravenous labetalol with the goal to reduce BP by 15% to 20% in the first hour. The BP was rechecked after an hour of starting labetalol and was 165/100 mm Hg. MRI of the brain was performed in the emergency department and demonstrated multiple scattered areas of increased signal intensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in both the occipital and posterior parietal lobes. There were also similar lesions in both hemispheres of the cerebellum (especially the cerebellar white matter on the left) as well as in the medulla oblongata. The lesions were not associated with mass effect, and after contrast administration, there was no evidence of abnormal enhancement. In the emergency department, his BP decreased to 160/95 mm Hg, and he was transitioned from drip to oral medications and transferred to the telemetry floor. How would you manage this case?

The patient initially presented with headache, nausea, vomiting, blurred vision, and confusion. The patient’s BP was found to be 195/123 mm Hg, and MRI of the brain demonstrated scattered lesions with increased intensity in the occipital and posterior parietal lobes, as well as in cerebellum and medulla oblongata. The clinical presentation, elevated BP, and brain MRI findings were suggestive of hypertensive emergency, more specifically hypertensive encephalopathy. These MRI changes can be seen particularly in posterior reversible encephalopathy syndrome (PRES), a sequela of hypertensive encephalopathy. BP was initially controlled by labetalol, and after satisfactory control of BP, the patient was switched to oral antihypertensive medications.

Hypertensive emergency refers to the elevation of systolic BP >180 mm Hg and/or diastolic BP >120 mm Hg that is associated with end-organ damage; however, in some conditions such as pregnancy, more modest BP elevation can constitute an emergency. An equal degree of hypertension but without end-organ damage constitutes a hypertensive urgency, the treatment of which requires gradual BP reduction over several hours. Patients with hypertensive emergency require rapid, tightly controlled reductions in BP that avoid overcorrection. Management typically occurs in an intensive care setting with continuous arterial BP monitoring and continuous infusion of antihypertensive agents.

Sign in or create a free Access profile below to access even more exclusive content.

With an Access profile, you can save and manage favorites from your personal dashboard, complete case quizzes, review Q&A, and take these feature on the go with our Access app.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

• Skip to primary navigation
• Skip to main content
• Skip to primary sidebar
• Skip to footer

Making Best Practice, Every Day Practice

Case study: The hypertensive patient

Working with patients who are not willing to engage fully with healthcare services is a common occurrence. The process requires patience and a focus on providing the patient with full information about their condition and then allowing them to make decisions about their treatment. Here, Dr Terry McCormack (GP and Cardiovascular Lead, North Yorks) describes the approach of his practice to a man with hypertension.

A 57-year old man Mr ‘Hawk’ Ward attends a routine NHS Health Check with a health care assistant (HCA) in the local surgery. He had had no contact with healthcare for many years and was not keen on any interventions. Repeated blood pressure (BP) measurements showed very high BP of 205/91 mmHg. The assessment also showed:

• A strong family history of CV disease (brother
• Smoker 30/day
• Appearance healthy
• Alcohol intake 100 units/week

The HCA immediately referred him to the GP who had a long discussion with him and was able to persuade him to take a blood test and have home blood pressure monitoring (HBPM) although he declined ambulatory blood pressure monitoring.

He returned to see the practice senior nurse after HBPM and further investigations showed:

• HBPM average of 8 readings (first 2 discounted) 180/95 mmHg
• Total cholesterol 7.2 mmol/L, HDL 1.4 mmol/L, non-HDL 5.8 mmol/L
• QRISK2 36.1
• Liver Function Tests normal

Mr Ward agreed with the senior nurse to stop smoking, excess alcohol intake, adding salt to food, but would not take medication.  He reluctantly agreed to make an appointment to see Dr McCormack.

At the GP appointment

• Mr Ward announces that ‘medication is not an option’
• The GP explains all his risks (including the relevance of non-HDL cholesterol and QRISK2 assessment) and then ask him what he would like to do about it.
• Shared, informed decision making explained
• The GP offers ABPM to confirm the diagnosis

After some time spent considering the GPs evidence and advice, the patient decided to accept some medication and was put on amlodipine 5mg.  

Current situation

At a later visit Mr Ward’s blood pressure had reduced to 147/84 mmHg. He has cut down on alcohol and was less agitated. He agreed to take atorvastatin 20 mg and is continuing on therapy and has improved his engagement with the practice team. This patient and ongoing approach has produced significant improvements in his condition, lowered his risk of subsequent events and provides promise for ongoing interaction with health care services.

Case study: Nurse COPD assessment

Case study: Painful diabetic peripheral neuropathy

Case study: Statin intolerance in a patient with high cardiovascular risk

Join our community of primary care professionals today, educational partners.

Newly diagnosed hypertension: case study

Affiliation.

• 1 Trainee Advanced Nurse Practitioner, East Belfast GP Federation, Northern Ireland.
• PMID: 37344134
• DOI: 10.12968/bjon.2023.32.12.556

The role of an advanced nurse practitioner encompasses the assessment, diagnosis and treatment of a range of conditions. This case study presents a patient with newly diagnosed hypertension. It demonstrates effective history taking, physical examination, differential diagnoses and the shared decision making which occurred between the patient and the professional. It is widely acknowledged that adherence to medications is poor in long-term conditions, such as hypertension, but using a concordant approach in practice can optimise patient outcomes. This case study outlines a concordant approach to consultations in clinical practice which can enhance adherence in long-term conditions.

Keywords: Adherence; Advanced nurse practitioner; Case study; Concordance; Hypertension.

• Diagnosis, Differential
• Hypertension* / diagnosis
• Hypertension* / drug therapy
• Nurse Practitioners*

This website is intended for healthcare professionals

• { $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Abegaz TM, Shehab A, Gebreyohannes EA, Bhagavathula AS, Elnour AA. Nonadherence to antihypertensive drugs. Medicine (Baltimore). 2017; 96:(4) https://doi.org/10.1097/MD.0000000000005641

Armitage LC, Davidson S, Mahdi A Diagnosing hypertension in primary care: a retrospective cohort study to investigate the importance of night-time blood pressure assessment. Br J Gen Pract. 2023; 73:(726)e16-e23 https://doi.org/10.3399/BJGP.2022.0160

Barratt J. Developing clinical reasoning and effective communication skills in advanced practice. Nurs Stand. 2018; 34:(2)48-53 https://doi.org/10.7748/ns.2018.e11109

Bostock-Cox B. Nurse prescribing for the management of hypertension. British Journal of Cardiac Nursing. 2013; 8:(11)531-536

Bostock-Cox B. Hypertension – the present and the future for diagnosis. Independent Nurse. 2019; 2019:(1)20-24 https://doi.org/10.12968/indn.2019.1.20

Chakrabarti S. What's in a name? Compliance, adherence and concordance in chronic psychiatric disorders. World J Psychiatry. 2014; 4:(2)30-36 https://doi.org/10.5498/wjp.v4.i2.30

De Mauri A, Carrera D, Vidali M Compliance, adherence and concordance differently predict the improvement of uremic and microbial toxins in chronic kidney disease on low protein diet. Nutrients. 2022; 14:(3) https://doi.org/10.3390/nu14030487

Demosthenous N. Consultation skills: a personal reflection on history-taking and assessment in aesthetics. Journal of Aesthetic Nursing. 2017; 6:(9)460-464 https://doi.org/10.12968/joan.2017.6.9.460

Diamond-Fox S. Undertaking consultations and clinical assessments at advanced level. Br J Nurs. 2021; 30:(4)238-243 https://doi.org/10.12968/bjon.2021.30.4.238

Diamond-Fox S, Bone H. Advanced practice: critical thinking and clinical reasoning. Br J Nurs. 2021; 30:(9)526-532 https://doi.org/10.12968/bjon.2021.30.9.526

Donnelly M, Martin D. History taking and physical assessment in holistic palliative care. Br J Nurs. 2016; 25:(22)1250-1255 https://doi.org/10.12968/bjon.2016.25.22.1250

Fawcett J. Thoughts about meanings of compliance, adherence, and concordance. Nurs Sci Q. 2020; 33:(4)358-360 https://doi.org/10.1177/0894318420943136

Fisher NDL, Curfman G. Hypertension—a public health challenge of global proportions. JAMA. 2018; 320:(17)1757-1759 https://doi.org/10.1001/jama.2018.16760

Green S. Assessment and management of acute sore throat. Pract Nurs. 2015; 26:(10)480-486 https://doi.org/10.12968/pnur.2015.26.10.480

Harper C, Ajao A. Pendleton's consultation model: assessing a patient. Br J Community Nurs. 2010; 15:(1)38-43 https://doi.org/10.12968/bjcn.2010.15.1.45784

Hitchings A, Lonsdale D, Burrage D, Baker E. The Top 100 Drugs; Clinical Pharmacology and Practical Prescribing, 2nd edn. Scotland: Elsevier; 2019

Hobden A. Strategies to promote concordance within consultations. Br J Community Nurs. 2006; 11:(7)286-289 https://doi.org/10.12968/bjcn.2006.11.7.21443

Ingram S. Taking a comprehensive health history: learning through practice and reflection. Br J Nurs. 2017; 26:(18)1033-1037 https://doi.org/10.12968/bjon.2017.26.18.1033

James A, Holloway S. Application of concepts of concordance and health beliefs to individuals with pressure ulcers. British Journal of Healthcare Management. 2020; 26:(11)281-288 https://doi.org/10.12968/bjhc.2019.0104

Jamison J. Differential diagnosis for primary care. A handbook for health care practitioners, 2nd edn. China: Churchill Livingstone Elsevier; 2006

History and Physical Examination. 2021. https://patient.info/doctor/history-and-physical-examination (accessed 26 January 2023)

Kumar P, Clark M. Clinical Medicine, 9th edn. The Netherlands: Elsevier; 2017

Matthys J, Elwyn G, Van Nuland M Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2009; 59:(558)29-36 https://doi.org/10.3399/bjgp09X394833

McKinnon J. The case for concordance: value and application in nursing practice. Br J Nurs. 2013; 22:(13)766-771 https://doi.org/10.12968/bjon.2013.22.13.766

McPhillips H, Wood AF, Harper-McDonald B. Conducting a consultation and clinical assessment of the skin for advanced clinical practitioners. Br J Nurs. 2021; 30:(21)1232-1236 https://doi.org/10.12968/bjon.2021.30.21.1232

Moulton L. The naked consultation; a practical guide to primary care consultation skills.Abingdon: Radcliffe Publishing; 2007

Medicine adherence; involving patients in decisions about prescribed medications and supporting adherence.England: NICE; 2009

National Institute for Health and Care Excellence. How do I control my blood pressure? Lifestyle options and choice of medicines patient decision aid. 2019. https://www.nice.org.uk/guidance/ng136/resources/patient-decision-aid-pdf-6899918221 (accessed 25 January 2023)

National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. NICE guideline NG136. 2022. https://www.nice.org.uk/guidance/ng136 (accessed 15 June 2023)

Nazarko L. Healthwise, Part 4. Hypertension: how to treat it and how to reduce its risks. Br J Healthc Assist. 2021; 15:(10)484-490 https://doi.org/10.12968/bjha.2021.15.10.484

Neighbour R. The inner consultation.London: Radcliffe Publishing Ltd; 1987

The Code. professional standards of practice and behaviour for nurses, midwives and nursing associates.London: NMC; 2018

Nuttall D, Rutt-Howard J. The textbook of non-medical prescribing, 2nd edn. Chichester: Wiley-Blackwell; 2016

O'Donovan K. The role of ACE inhibitors in cardiovascular disease. British Journal of Cardiac Nursing. 2018; 13:(12)600-608 https://doi.org/10.12968/bjca.2018.13.12.600

O'Donovan K. Angiotensin receptor blockers as an alternative to angiotensin converting enzyme inhibitors. British Journal of Cardiac Nursing. 2019; 14:(6)1-12 https://doi.org/10.12968/bjca.2019.0009

Porth CM. Essentials of Pathophysiology, 4th edn. Philadelphia: Wolters Kluwer; 2015

Rae B. Obedience to collaboration: compliance, adherence and concordance. Journal of Prescribing Practice. 2021; 3:(6)235-240 https://doi.org/10.12968/jprp.2021.3.6.235

Rostoft S, van den Bos F, Pedersen R, Hamaker ME. Shared decision-making in older patients with cancer - What does the patient want?. J Geriatr Oncol. 2021; 12:(3)339-342 https://doi.org/10.1016/j.jgo.2020.08.001

Schroeder K. The 10-minute clinical assessment, 2nd edn. Oxford: Wiley Blackwell; 2017

Thomas J, Monaghan T. The Oxford handbook of clinical examination and practical skills, 2nd edn. Oxford: Oxford University Press; 2014

Vincer K, Kaufman G. Balancing shared decision-making with ethical principles in optimising medicines. Nurse Prescribing. 2017; 15:(12)594-599 https://doi.org/10.12968/npre.2017.15.12.594

Waterfield J. ACE inhibitors: use, actions and prescribing rationale. Nurse Prescribing. 2008; 6:(3)110-114 https://doi.org/10.12968/npre.2008.6.3.28858

Weiss M. Concordance, 6th edn. In: Watson J, Cogan LS Poland: Elsevier; 2019

Williams H. An update on hypertension for nurse prescribers. Nurse Prescribing. 2013; 11:(2)70-75 https://doi.org/10.12968/npre.2013.11.2.70

Adherence to long-term therapies, evidence for action.Geneva: WHO; 2003

Young K, Franklin P, Franklin P. Effective consulting and historytaking skills for prescribing practice. Br J Nurs. 2009; 18:(17)1056-1061 https://doi.org/10.12968/bjon.2009.18.17.44160

Newly diagnosed hypertension: case study

Angela Brown

Trainee Advanced Nurse Practitioner, East Belfast GP Federation, Northern Ireland

View articles · Email Angela

The role of an advanced nurse practitioner encompasses the assessment, diagnosis and treatment of a range of conditions. This case study presents a patient with newly diagnosed hypertension. It demonstrates effective history taking, physical examination, differential diagnoses and the shared decision making which occurred between the patient and the professional. It is widely acknowledged that adherence to medications is poor in long-term conditions, such as hypertension, but using a concordant approach in practice can optimise patient outcomes. This case study outlines a concordant approach to consultations in clinical practice which can enhance adherence in long-term conditions.

Hypertension is a worldwide problem with substantial consequences ( Fisher and Curfman, 2018 ). It is a progressive condition ( Jamison, 2006 ) requiring lifelong management with pharmacological treatments and lifestyle adjustments. However, adopting these lifestyle changes can be notoriously difficult to implement and sustain ( Fisher and Curfman, 2018 ) and non-adherence to chronic medication regimens is extremely common ( Abegaz et al, 2017 ). This is also recognised by the National Institute for Health and Care Excellence (NICE) (2009) which estimates that between 33.3% and 50% of medications are not taken as recommended. Abegaz et al (2017) furthered this by claiming 83.7% of people with uncontrolled hypertension do not take medications as prescribed. However, leaving hypertension untreated or uncontrolled is the single largest cause of cardiovascular disease ( Fisher and Curfman, 2018 ). Therefore, better adherence to medications is associated with better outcomes ( World Health Organization, 2003 ) in terms of reducing the financial burden associated with the disease process on the health service, improving outcomes for patients ( Chakrabarti, 2014 ) and increasing job satisfaction for professionals ( McKinnon, 2013 ). Therefore, at a time when growing numbers of patients are presenting with hypertension, health professionals must adopt a concordant approach from the initial consultation to optimise adherence.

Great emphasis is placed on optimising adherence to medications ( NICE, 2009 ), but the meaning of the term ‘adherence’ is not clear and it is sometimes used interchangeably with compliance and concordance ( De Mauri et al, 2022 ), although they are not synonyms. Compliance is an outdated term alluding to paternalism, obedience and passivity from the patient ( Rae, 2021 ), whereby the patient's behaviour must conform to the health professional's recommendations. Adherence is defined as ‘the extent to which a person's behaviour, taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’ ( Chakrabarti, 2014 ). This term is preferred over compliance as it is less paternalistic ( Rae, 2021 ), as the patient is included in the decision-making process and has agreed to the treatment plan. While it is not yet widely embraced or used in practice ( Fawcett, 2020 ), concordance is recognised, not as a behaviour ( Rae, 2021 ) but more an approach or method which focuses on the equal partnership between patient and professional ( McKinnon, 2013 ) and enables effective and agreed treatment plans.

NICE last reviewed its guidance on medication adherence in 2019 and did not replace adherence with concordance within this. This supports the theory that adherence is an outcome of good concordance and the two are not synonyms. NICE (2009) guidelines, which are still valid, show evidence of concordant principles to maximise adherence. Integrating the theoretical principles of concordance into this case study demonstrates how the trainee advanced nurse practitioner aimed to individualise patient-centred care and improve health outcomes through optimising adherence.

Patient introduction and assessment

Jane (a pseudonym has been used to protect the patient's anonymity; Nursing and Midwifery Council (NMC) 2018 ), is a 45-year-old woman who had been referred to the surgery following an attendance at an emergency department. Jane had been role-playing as a patient as part of a teaching session for health professionals when it was noted that her blood pressure was significantly elevated at 170/88 mmHg. She had no other symptoms. Following an initial assessment at the emergency department, Jane was advised to contact her GP surgery for review and follow up. Nazarko (2021) recognised that it is common for individuals with high blood pressure to be asymptomatic, contributing to this being referred to as the ‘silent killer’. Hypertension is generally only detected through opportunistic checking of blood pressure, as seen in Jane's case, which is why adults over the age of 40 years are offered a blood pressure check every 5 years ( Bostock-Cox, 2013 ).

Consultation

Jane presented for a consultation at the surgery. Green (2015) advocates using a model to provide a structured approach to consultations which ensures quality and safety, and improves time management. Young et al (2009) claimed that no single consultation model is perfect, and Diamond-Fox (2021) suggested that, with experience, professionals can combine models to optimise consultation outcomes. Therefore, to effectively consult with Jane and to adapt to her individual personality, different models were intertwined to provide better person-centred care.

The Calgary–Cambridge model is the only consultation model that places emphasis on initiating the session, despite it being recognised that if a consultation gets off to a bad start this can interfere throughout ( Young et al, 2009 ). Being prepared for the consultation is key. Before Jane's consultation, the environment was checked to minimise interruptions, ensuring privacy and dignity ( Green, 2015 ; NMC, 2018 ), the seating arrangements optimised to aid good body language and communication ( Diamond-Fox, 2021 ) and her records were viewed to give some background information to help set the scene and develop a rapport ( Young et al, 2009 ). Being adequately prepared builds the patient's trust and confidence in the professional ( Donnelly and Martin, 2016 ) but equally viewing patient information can lead to the professional forming preconceived ideas ( Donnelly and Martin, 2016 ). Therefore, care was taken by the trainee advanced nurse practitioner to remain open-minded.

During Jane's consultation, a thorough clinical history was taken ( Table 1 ). History taking is common to all consultation models and involves gathering important information ( Diamond-Fox, 2021 ). History-taking needs to be an effective ( Bostock-Cox, 2019 ), holistic process ( Harper and Ajao, 2010 ) in order to be thorough, safe ( Diamond-Fox, 2021 ) and aid in an accurate diagnosis. The key skill for taking history is listening and observing the patient ( Harper and Ajao, 2010 ). Sir William Osler said:‘listen to the patient as they are telling you the diagnosis’, but Knott and Tidy (2021) suggested that patients are barely given 20 seconds before being interrupted, after which they withdraw and do not offer any new information ( Demosthenous, 2017 ). Using this guidance, Jane was given the ‘golden minute’ allowing her to tell her ‘story’ without being interrupted ( Green, 2015 ). This not only showed respect ( Ingram, 2017 ) but interest in the patient and their concerns.

Once Jane shared her story, it was important for the trainee advanced nurse practitioner to guide the questioning ( Green 2015 ). This was achieved using a structured approach to take Jane's history, which optimised efficiency and effectiveness, and ensured that pertinent information was not omitted ( Young et al, 2009 ). Thomas and Monaghan (2014) set out clear headings for this purpose. These included:

• The presenting complaint
• Past medical history
• Drug history
• Social history
• Family history.

McPhillips et al (2021) also emphasised a need for a systemic enquiry of the other body systems to ensure nothing is missed. From taking this history it was discovered that Jane had been feeling well with no associated symptoms or red flags. A blood pressure reading showed that her blood pressure was elevated. Jane had no past medical history or allergies. She was not taking any medications, including prescribed, over the counter, herbal or recreational. Jane confirmed that she did not drink alcohol or smoke. There was no family history to note, which is important to clarify as a genetic link to hypertension could account for 30–50% of cases ( Nazarko, 2021 ). The information gathered was summarised back to Jane, showing good practice ( McPhillips et al, 2021 ), and Jane was able to clarify salient or missing points. Green (2015) suggested that optimising the patient's involvement in this way in the consultation makes her feel listened to which enhances patient satisfaction, develops a therapeutic relationship and demonstrates concordance.

During history taking it is important to explore the patient's ideas, concerns and expectations. Moulton (2007) refers to these as the ‘holy trinity’ and central to upholding person-centredness ( Matthys et al, 2009 ). Giving Jane time to discuss her ideas, concerns and expectations allowed the trainee advanced nurse practitioner to understand that she was concerned about her risk of a stroke and heart attack, and worried about the implications of hypertension on her already stressful job. Using ideas, concerns and expectations helped to understand Jane's experience, attitudes and perceptions, which ultimately will impact on her health behaviours and whether engagement in treatment options is likely ( James and Holloway, 2020 ). Establishing Jane's views demonstrated that she was eager to engage and manage her blood pressure more effectively.

Vincer and Kaufman (2017) demonstrated, through their case study, that a failure to ask their patient's viewpoint at the initial consultation meant a delay in engagement with treatment. They recognised that this delay could have been avoided with the use of additional strategies had ideas, concerns and expectations been implemented. Failure to implement ideas, concerns and expectations is also associated with reattendance or the patient seeking second opinions ( Green, 2015 ) but more positively, when ideas, concerns and expectations is implemented, it can reduce the number of prescriptions while sustaining patient satisfaction ( Matthys et al, 2009 ).

Physical examination

Once a comprehensive history was taken, a physical examination was undertaken to supplement this information ( Nuttall and Rutt-Howard, 2016 ). A physical examination of all the body systems is not required ( Diamond-Fox, 2021 ) as this would be extremely time consuming, but the trainee advanced nurse practitioner needed to carefully select which systems to examine and use good examination technique to yield a correct diagnosis ( Knott and Tidy, 2021 ). With informed consent, clinical observations were recorded along with a full cardiovascular examination. The only abnormality discovered was Jane's blood pressure which was 164/90 mmHg, which could suggest stage 2 hypertension ( NICE, 2019 ; 2022 ). However, it is the trainee advanced nurse practitioner's role to use a hypothetico-deductive approach to arrive at a diagnosis. This requires synthesising all the information from the history taking and physical examination to formulate differential diagnoses ( Green, 2015 ) from which to confirm or refute before arriving at a final diagnosis ( Barratt, 2018 ).

Differential diagnosis

Hypertension can be triggered by secondary causes such as certain drugs (non-steroidal anti-inflammatory drugs, steroids, decongestants, sodium-containing medications or combined oral contraception), foods (liquorice, alcohol or caffeine; Jamison, 2006 ), physiological response (pain, anxiety or stress) or pre-eclampsia ( Jamison, 2006 ; Schroeder, 2017 ). However, Jane had clarified that these were not contributing factors. Other potential differentials which could not be ruled out were the white-coat syndrome, renal disease or hyperthyroidism ( Schroeder, 2017 ). Further tests were required, which included bloods, urine albumin creatinine ratio, electrocardiogram and home blood pressure monitoring, to ensure a correct diagnosis and identify any target organ damage.

Joint decision making

At this point, the trainee advanced nurse practitioner needed to share their knowledge in a meaningful way to enable the patient to participate with and be involved in making decisions about their care ( Rostoft et al, 2021 ). Not all patients wish to be involved in decision making ( Hobden, 2006 ) and this must be respected ( NMC, 2018 ). However, engaging patients in partnership working improves health outcomes ( McKinnon, 2013 ). Explaining the options available requires skill so as not to make the professional seem incompetent and to ensure the patient continues to feel safe ( Rostoft et al, 2021 ).

Information supported by the NICE guidelines was shared with Jane. These guidelines advocated that in order to confirm a diagnosis of hypertension, a clinic blood pressure reading of 140/90 mmHg or higher was required, with either an ambulatory or home blood pressure monitoring result of 135/85 mmHg or higher ( NICE, 2019 ; 2022 ). However, the results from a new retrospective study suggested that the use of home blood pressure monitoring is failing to detect ‘non-dippers’ or ‘reverse dippers’ ( Armitage et al, 2023 ). These are patients whose blood pressure fails to fall during their nighttime sleep. This places them at greater risk of cardiovascular disease and misdiagnosis if home blood pressure monitors are used, but ambulatory blood pressure monitors are less frequently used in primary care and therefore home blood pressure monitors appear to be the new norm ( Armitage et al, 2023 ).

Having discussed this with Jane she was keen to engage with home blood pressure monitoring in order to confirm the potential diagnosis, as starting a medication without a true diagnosis of hypertension could potentially cause harm ( Jamison, 2006 ). An accurate blood pressure measurement is needed to prevent misdiagnosis and unnecessary therapy ( Jamison, 2006 ) and this is dependent on reliable and calibrated equipment and competency in performing the task ( Bostock-Cox, 2013 ). Therefore, Jane was given education and training to ensure the validity and reliability of her blood pressure readings.

For Jane, this consultation was the ideal time to offer health promotion advice ( Green, 2015 ) as she was particularly worried about her elevated blood pressure. Offering health promotion advice is a way of caring, showing support and empowerment ( Ingram, 2017 ). Therefore, Jane was provided with information on a healthy diet, the reduction of salt intake, weight loss, exercise and continuing to abstain from smoking and alcohol ( Williams, 2013 ). These were all modifiable factors which Jane could implement straight away to reduce her blood pressure.

Safety netting

The final stage and bringing this consultation to a close was based on the fourth stage of Neighbour's (1987) model, which is safety netting. Safety netting identifies appropriate follow up and gives details to the patient on what to do if their condition changes ( Weiss, 2019 ). It is important that the patient knows who to contact and when ( Young et al, 2009 ). Therefore, Jane was advised that, should she develop chest pains, shortness of breath, peripheral oedema, reduced urinary output, headaches, visual disturbances or retinal haemorrhages ( Schroeder, 2017 ), she should present immediately to the emergency department, otherwise she would be reviewed in the surgery in 1 week.

Jane was followed up in a second consultation 1 week later with her home blood pressure readings. The average reading from the previous 6 days was calculated ( Bostock-Cox, 2013 ) and Jane's home blood pressure reading was 158/82 mmHg. This reading ruled out white-coat syndrome as Jane's blood pressure remained elevated outside clinic conditions (white-coat syndrome is defined as a difference of more than 20/10 mmHg between clinic blood pressure readings and the average home blood pressure reading; NICE, 2019 ; 2022 ). Subsequently, Jane was diagnosed with stage 2 essential (or primary) hypertension. Stage 2 is defined as a clinic blood pressure of 160/100 mmHg or higher or a home blood pressure of 150/95 mmHg or higher ( NICE, 2019 ; 2022 ).

A diagnosis of hypertension can be difficult for patients as they obtain a ‘sick label’ despite feeling well ( Jamison, 2006 ). This is recognised as a deterrent for their motivation to initiate drug treatment and lifestyle changes ( Williams, 2013 ), presenting a greater challenge to health professionals, which can be addressed through concordance strategies. However, having taken Jane's bloods, electrocardiogram and urine albumin:creatinine ratio in the first consultation, it was evident that there was no target organ damage and her Qrisk3 score was calculated as 3.4%. These results provided reassurance for Jane, but she was keen to engage and prevent any potential complications.

Agreeing treatment

Concordance is only truly practised when the patient's perspectives are valued, shared and used to inform planning ( McKinnon, 2013 ). The trainee advanced nurse practitioner now needed to use the information gained from the consultations to formulate a co-produced and meaningful treatment plan based on the best available evidence ( Diamond-Fox and Bone, 2021 ). Jane understood the risk associated with high blood pressure and was keen to begin medication as soon as possible. NICE guidelines ( 2019 ; 2022 ) advocate the use of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blockers in patients under 55 years of age and not of Black African or African-Caribbean origin. However, ACE inhibitors seem to be used as the first-line treatment for hypertensive patients under the age of 55 years ( O'Donovan, 2019 ).

ACE inhibitors directly affect the renin–angiotensin-aldosterone system which plays a central role in regulation of blood pressure ( Porth, 2015 ). Renin is secreted by the juxtaglomerular cells, in the kidneys' nephrons, when there is a decrease in renal perfusion and stimulation of the sympathetic nervous system ( O'Donovan, 2018 ). Renin then combines with angiotensinogen, a circulating plasma globulin from the liver, to form angiotensin I ( Kumar and Clark, 2017 ). Angiotensin I is inactive but, through ACE, an enzyme present in the endothelium of the lungs, it is transformed into angiotensin II ( Kumar and Clark, 2017 ). Angiotensin II is a vasoconstrictor which increases vascular resistance and in turn blood pressure ( Porth, 2015 ) while also stimulating the adrenal gland to produce aldosterone. Aldosterone reduces sodium excretion in the kidneys, thus increasing water reabsorption and therefore blood volume ( Porth, 2015 ). Using an ACE inhibitor prevents angiotensin II formation, which prevents vasoconstriction and stops reabsorption of sodium and water, thus reducing blood pressure.

When any new medication is being considered, providing education is key. This must include what the medication is for, the importance of taking it, any contraindications or interactions with the current medications being taken by the patient and the potential risk of adverse effects ( O'Donovan, 2018 ). Sharing this information with Jane allowed her to weigh up the pros and cons and make an informed choice leading to the creation of an individualised treatment plan.

Jamison (2006) placed great emphasis on sharing information about adverse effects, because patients with hypertension feel well before commencing medications, but taking medication has the potential to cause side effects which can affect adherence. Therefore, the range of side effects were discussed with Jane. These include a persistent, dry non-productive cough, hypotension, hypersensitivity, angioedema and renal impairment with hyperkalaemia ( Hitchings et al, 2019 ). ACE inhibitors have a range of adverse effects and most resolve when treatment is stopped ( Waterfield, 2008 ).

Following discussion with Jane, she proceeded with taking an ACE inhibitor and was encouraged to report any side effects in order to find another more suitable medication and to prevent her hypertension from going untreated. This information was provided verbally and written which is seen as good practice ( Green, 2015 ). Jane was followed up with fortnightly blood pressure recordings and urea and electrolyte checks and her dose of ramipril was increased fortnightly until her blood pressure was under 140/90 mmHg ( NICE, 2019 ; 2022 ).

Conclusions

Adherence to medications can be difficult to establish and maintain, especially for patients with long-term conditions. This can be particularly challenging for patients with hypertension because they are generally asymptomatic, yet acquire a sick label and start lifelong medication and lifestyle adjustments to prevent complications. Through adopting a concordant approach in practice, the outcome of adherence can be increased. This case study demonstrates how concordant strategies were implemented throughout the consultation to create a therapeutic patient–professional relationship. This optimised the creation of an individualised treatment plan which the patient engaged with and adhered to.

• Hypertension is a growing worldwide problem
• Appropriate clinical assessment, diagnosis and management is key to prevent misdiagnosis
• Long-term conditions are associated with high levels of non-adherence to treatments
• Adopting a concordance approach to practice optimises adherence and promotes positive patient outcomes

CPD reflective questions

• How has this article developed your assessment, diagnosis or management of patients presenting with a high blood pressure?
• What measures can you implement in your practice to enhance a concordant approach?

• Open access
• Published: 15 September 2020

Treatment adherence among patients with hypertension: findings from a cross-sectional study

• Fahad M. Algabbani 1 &
• Aljoharah M. Algabbani 2  

Clinical Hypertension volume  26 , Article number:  18 ( 2020 ) Cite this article

13k Accesses

32 Citations

Metrics details

Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of mortality globally. Patient’s adherence to treatment is a cornerstone factor in controlling hypertension and its complications. This study assesses hypertension patients’ adherence to treatment and its associated factors.

This cross-sectional study conducted in Riyadh, Saudi Arabia. The study targeted outpatients aged ≥18 years who were diagnosed with hypertension. Participants were recruited using a systemic sampling technique. The two main measurements were assessing adherence rate of antihypertensive medications using Morisky scale and identifying predictors of poor medication adherence among hypertensive patients including socio-economic and demographic data, health status, clinic visits, medication side effects, medications availability, and knowledge. Descriptive and logistic regression analyses were performed to assess factors associated with poor adherence.

A total of 306 hypertensive outpatients participated in this study. 42.2% of participants were adherent to antihypertensive medications. Almost half of participants (49%) who reported having no comorbidities were adherent to antihypertensive medications compared to participants with one or more than one comorbidities 41, 39% respectively. The presence of comorbid conditions and being on multiple medications were significantly associated with medication adherence ( P -values, respectively, < 0.004, < 0.009). Patients with good knowledge about the disease and its complications were seven times more likely to have good adherence to medication ( P  <  0.001).

Conclusions

Non-adherence to medications is prevalent among a proportion of hypertensive patients which urges continuous monitoring to medication adherence with special attention to at risks groups of patients. Patients with comorbidities and on multiple medications were at high risk of medication non-adherence. Patients’ knowledge on the disease was one of the main associated factors with non-adherence.

Hypertension is one of the most common chronic diseases in Saudi Arabia and a rising health burden, affecting 26.1% adult population [ 1 ]. Hypertension is a major risk factor for heart failure, myocardial infarction, cerebrovascular disease, and renal failure [ 2 ]. Controlling hypertension reduces the risk of cerebrovascular accident (CVA), coronary heart disease, congestive heart failure, and mortality [ 2 , 3 ]. There are several factors that affect blood pressure control. Patients’ adherence to treatment is one of the major factors in controlling blood pressure and preventing hypertension complications [ 3 ]. The World Health Organization (WHO) defines adherence to long-term therapy as “the extent to which a person’s behavior-taking medication, following a diet, and/or executing lifestyle changes-corresponds with agreed recommendations from a healthcare provider” [ 3 ]. Patients with a high level of medication adherence were found to have better blood pressure control [ 4 ]. Still, adherence to hypertension treatment is challenging, due to the asymptomatic nature of the disease [ 5 ].

Several studies investigated the adherence rate among hypertension patients and sociodemographic factors affecting medication adherence including age, gender, comorbidities, patients’ knowledge about the disease, the number of medications. A study conducted in Saudi Arabia showed that only 34.7% of male hypertensive patients were found to be adherent to their medication [ 6 ]. The study reported a negative association between the presence of comorbidities and the adherence level [ 6 ]. A cross-sectional study on medication adherence among patients with hypertension in Malaysia, found an association between adherence and good knowledge of the medications and disease [ 7 ]. The study also found that the increase in the number of drugs patients taking has a negative effect on medication adherence [ 7 ]. Other studies had similar findings regarding the association between the number of medications and adherence [ 8 , 9 , 10 ]. In a cross-sectional study conducted in Iran, older patients reported high adherence to antihypertensive medication and better knowledge of their disease than younger patients [ 9 ]. However, number of studies reported no significant associations between age and medication adherence [ 8 , 11 ]. Female patients were more likely to adhere to their medication, compared to males [ 12 ]. Another study on the prevalence and predictors of poor antihypertensive reported that male patients were more adherent than female patients [ 13 ]. Some studies reported no relationship between gender and adherence [ 9 , 11 ].

Educational level and health literacy were shown to be associated with medication adherence. A cross-sectional study conducted in Iraq showed that adherence decreased in patients with primary and secondary school education, while no significant difference among patients with higher education and undereducated patients [ 14 ]. Similar results found in a systematic review conducted in hypertension management and medication adherence [ 15 ]. On the other hand, no association between educational level and adherence was found in a study conducted in Saudi Arabia [ 8 ]. However, good health knowledge of hypertension shown to be associated with good adherence to medication treatment in several studies [ 7 , 11 ]. Two cross-sectional studies conducted in Turkey and Algeria showed a significant association between knowledge of complications related to hypertension and good adherence to antihypertensive therapy [ 16 , 17 ].

Hypertension is one of the major health issues in Saudi Arabia; affecting more than a quarter of the Saudi adult population [ 1 ]. Only 37% of hypertensive patients on medication have their blood pressure controlled [ 18 ]. Non-adherence to antihypertensive medications is a potential contributing factor to uncontrolled hypertension. With limited studies conducted to investigate this challenging issue, this cross-sectional study aims to assess the adherence rate among hypertensive patients and associated factors affecting adherence to antihypertensive medications.

Study design and sampling

This cross-sectional study was conducted to determine the adherence rate of antihypertensive medications and the predictors of poor medication adherence among hypertensive patients at primary health clinics (PHCs) in Prince Sultan Medical City (PSMMC) in Riyadh the capital city of Saudi Arabia. Single population proportion formula was used to calculate the sample size based on the prevalence of hypertension in Saudi Arabia (26.1%) [ 1 ]. With a 95% confidence level and a 5% margin of error, a total of 306 randomly selected outpatients with hypertension following up at primary health clinics were included in this study.

Participants recruitment

Participants in this study were recruited using a systemic sampling technique. Every fourth consecutive patient who fits the criteria was included. Arabic speaker patients older than 18 years who have been diagnosed with hypertension for more than three months were included in this study. Patients who do not speak Arabic had mental retardation, secondary hypertension, or who were younger than 18 years old were excluded from the study. The data was collected using a self-administered questionnaire that was distributed in the waiting area of the pharmacy. Illiterate participants were interviewed by a trained data collector. Before participants’ recruitment in the study, informed consent was obtained from all patients after a full explanation of the study. The study was approved and supervised by the institution review board (IRB) of Prince Sultan Medical City.

Measurements

The questionnaire consists of four main sections. The first section assesses participants’ socio-economic factors including age, gender, marital status, occupation, the highest level of education currently attained, occupation, and monthly income. The second section assesses the factors affecting medication adherence including comorbidities, number of medications, number of daily doses, number of clinic visits, the distance to the clinic, medication side effects, medication availability at the pharmacy. The third section aimed to assess patients’ adherence to treatment. The fourth part assesses the patients’ knowledge about hypertension.

Medication adherence was assessed using the 8- items Morisky scale [ 19 ]. Morisky scale has been validated and found to be reliable (α = .83) [ 20 ]. The scale is based on the patients’ self-response and consists of eight questions, seven items with yes or no response, and one item with a 5-point Likert scale response option. The total score ranges from 1 to 8, the patient whose adherence score was six or more is considered adherent. For linguistic validation, questions were translated forward and backward into Arabic by an independent translator.

The participant’s knowledge about hypertension was assessed using nine structured questions. The questions focused on different aspects of hypertension, namely blood pressure target, lifestyle modification effect, complications, treatment, and cure. During analysis, patients who answered < 70% were considered to have low knowledge and patient how answered ≥70% of the questions were considered to have good knowledge. The 70 % cut-off is based on the minimally acceptable level of quality control at PSMMC [ 21 ].

The questionnaire was pre-tested and then a pilot survey was conducted on 20 patients for clarity and feasibility. The questionnaire was also evaluated and reviewed by two independent family medicine consultants at Prince Sultan Medical City for validation.

Data analysis

Frequencies and percentages were used to assess participants’ characteristics. Chi-square analysis was used to determine the association between demographic, socioeconomic, and clinical factors with medication adherence. Logistic regression analysis was performed to assess factors associated with poor adherence. The variables were analyzed collectively using logistic regression to study the potential factors to avoid confounding bias. The association was considered statistically significant if the P -value was less than 0.05. Statistical Package for Social Sciences version 25 and Statistical Analysis System version 9.4 was used for data analysis.

A total of 306 outpatients who have hypertension participated in this study. Approximately 43% of the participants’ ages range was between 56 and 65. The majority of participants were married (92%), employed (61%), and had a high school diploma or above (80%). Most of the participants were middle income in the 5000–10,000 Saudi Riyal range of monthly income. Nearly one-third (28.1%) of the respondents in this study had no comorbidities while two-thirds reported having one or more comorbidities. The demographic, and socioeconomic clinical characteristics of the participants are presented in Table  1 .

Only 13% of the respondents live at a distance of less than half an hour from the clinic. Of the total participants, 14.1% reported visiting the primary health clinic once in the last year, 29.4% twice, 24.2% three times. The majority of participants reported taking less than four medications a day and 31.4% reported taking four or more medications a day. As to antihypertensive medication side effects, 19.6% reported having medication side effects. Only 4.9% of the participants reported that they stop taking their antihypertensive medications when they get sick. Approximately 9% of the participants reported that they stop taking their medications when it is not available at the pharmacy. Findings show that half (50.7%) of the participants were knowledgeable about the disease. The clinical characteristics of the participants are presented in Table 1 .

Figure  1 presents the percentage of participants’ adherence to antihypertensive treatment. Based on Morisky scale test results, 42.2% of the participants in this study were adherent to antihypertensive medications, while 57.8% were not adherent.

Distribution of patients according to their medication adherence status*

Table  2 presents the adherence rate in relation to the participants’ demographic, socioeconomic, and clinical characteristics. The presence of comorbid conditions is significantly associated with medication adherence ( P  <  0.001). Almost half of participants (49%) who reported having no comorbidities were adherent to antihypertensive medications compared to the participants with one or more than one comorbidities 41, 39% respectively. As for the number of medications, the adherence rate was found to be better among patients who were taking less than four medications (47.1%) compared to patients who were taking four or more medications (31.3%). Patients who visited the clinic once in the last year were more adherent than those who visited the clinic more than once ( p  < 0.05). No significant association between age, gender, income, educational level, and distance from home to the clinic.

The participants were asked eight questions about hypertension. Table  3 shows the distribution of the correct and incorrect answers giving by the participants. Most participants (64.4%) knew the target blood pressure for hypertensive patients and 40.8% think that hypertension can be cured. The majority (78%) knew that a low salt diet helps in lowering high blood pressure. Only 61% knew that hypertension can affect eyes and 13.4% reported that they stop taking their medication when they feel their blood pressure under control.

Adherence to antihypertensive medications among patients with good and poor knowledge levels about hypertension was assessed based on nine structured questions. Figure  2 shows the adherence to hypertension treatment among patients with good and poor knowledge level. 57.4% of patients with good knowledge levels were adherent compared to 42.6% who were not adherent. The majority (73.5%) of patients with poor knowledge levels were not adherent to treatment.

Adherence to hypertension treatment among patients with good and poor knowledge level*

Table  4 presents the factors associated with good adherence. When conducting binary logistic regression, knowledge about the disease was found to be significantly associated with adherence. Patients with good knowledge about the disease were seven times more likely to have good adherence to antihypertensive medications than those with poor knowledge (AOR 7.4 [95% CI: 4.177–13.121], p  < 0.001).

Several studies have investigated factors affecting medication adherence. This study shows that the level of adherence to antihypertensive medications is low. In this sample the adherence rate to hypertension treatment was found to be only 42%, which is similar to the study conducted in Al-Khobar and higher than the study conducted in Taif where adherence rate was found to be 47 and 34.7%, respectively [ 6 , 8 ]. Other studies conducted in different countries reported adherence rates ranging from 15 to 88% [ 22 , 23 , 24 , 25 ]. This discrepancy in adherence rate is potentially due to the differences in population characteristics, medication adherence assessment tools, and healthcare systems.

The association between sociodemographic and socioeconomic factors and adherence level has been investigated in several studies. In a study done in Hong Kong, older patients were found to be more adherent. However, in this study, there was no association between age and adherence. In another study done in the United States, female patients were less adherent to hypertension medication compared to male patients [ 13 ]. A study conducted in Malaysia reported that female patients were more adherent than male patients [ 22 ]. Our study showed that there was no significant relationship between gender and adherence. A meta-analysis suggested that the association between age, gender, and adherence level is weak [ 26 ]. The results of our study also demonstrate no significant relationship between marital status and educational level with adherence, which is similar to findings reported by other studies [ 9 , 27 ].

Previous research found that shorter traveling time from residence to the healthcare facility could increase patients’ adherence [ 28 ]. A study in Ethiopia found that the adherence level was lower in patients who lived more than 10 km from healthcare facilities [ 29 ]. A cross-sectional observational study done in Northwest Ethiopia indicated that patients who live less than 10 km from the healthcare facility had an adherence rate of 74% compared to 58% for patients who live far from the healthcare facility [ 29 ]. As the authors attributed this problem to poor infrastructure and lack of transportation in Ethiopia, the study suggested that shorter traveling time from residence to the healthcare facility could increase patients’ adherence [ 29 ]. In this study, distance from home to the clinic was not associated with hypertensive treatment. These differences may be due to the higher level of car ownership in Saudis Arabia which makes it easier to access health care facilities [ 30 ].

Only 8.8% of the participants reported not taking their medication when it is not available at the hospital pharmacy. This low percentage may be explained by the multiple community health centers in Saudi Arabia which provide free health care including medications dispensing. Moreover, the medication cost at private pharmacies in Saudi Arabia is affordable for most patients. According to the published Saudi Hypertension Management Guidelines the prices of the antihypertensive medications ranges between 7 to 118 Saudi Riyal (about 2 to 31 US Dollar) [ 31 ].

Many patients with hypertension will need two or more antihypertensive medications to achieve goal blood pressure [ 2 ]. In this sample significant association was observed between the number of medications and adherence level. The adherence rate among patients taking less than four medications was 47.1% compared to 31.3% to those who take four or more medications. Similarly, other studies reported the negative association between the number of medication and adherence levels [ 29 , 32 ].

Findings indicate that patients with multiple comorbidities were less adherent to antihypertensive medication, which is inconsistent with a previous study done in Taif which showed a negative association between the presence of comorbidity and adherence level [ 6 ]. This may be related to the fact that most patients with multiple comorbidities require taking multiple complex medications.

The result of our study showed that the patient who visited the clinic once in the last year were more adherent than the patient who visited the clinic more than once. This could be explained by that most patients with multiple comorbidities and on multiple medications frequently visit the clinic for issues related to their disease and to refill prescriptions.

Our study demonstrated the positive association between knowledge and adherence levels. Patients who had good knowledge were more adherent to the treatment [ 29 ]. Previous studies showed that patients who know the ideal target blood pressure level were more adherent to their medications [ 16 , 20 ]. In this study, only 64.4% of the participants knew the ideal target of blood pressure and 40.8% of the patients believe that hypertension can be cured. A study conducted in Rajshahi, Bangladesh found that 65.8% of the patients believe that hypertension is curable. Patients how have been educated by their physicians and healthcare providers were more adherents to treatment as they have a better understanding of the disease nature, the ideal target of blood pressure, and the complications of hypertension [ 33 ]. Therefore, patient education in disease nature and management is considered a key factor in the treatment of hypertension.

The study findings were based on self-reported survey. Self-reported data is a common method used in a cross-sectional study. However, self-reported data is subjected to biases such as response and recall biases that can lead to under- or overestimation of findings. On the other hand, adherence in this study was measured based on a validated self-report adherence scale and knowledge was tested based on evaluated and reviewed assessment items by two independent family medicine consultants. Moreover, this study conducted in one of the largest medical cities that serves a large community in the capital city Riyadh. Due to the study design and sampling method, study findings cannot be generalized and temporal relationships cannot be established between risk factors and adherence. Nevertheless, this study provides a snapshot of adherence to antihypertensive medication status and associated determinates among outpatients. Future large scale longitudinal studies will contribute to a better understanding of adherence status and associated factors among hypertensive patients.

Non-adherence to medications is prevalent in proportion of patients with hypertension. Therefore, there is an urge to continually monitor patients’ adherence to antihypertensive medication using a standardized scale. Patients with comorbidities and on multiple medications were at higher risk of non-adherence. There is a need to encourage patients on multiple medications to use adherence aids such as weekly pill organizers and medication alarm devices. Hypertensive patients’ knowledge of the disease and its complications was one of the main factors affecting patients’ adherence to treatment. Implementation of health awareness interventions and education programs intended for hypertensive patients will help improve medication adherence.

Availability of data and materials

The data sets generated during and/or analyzed during the current study are available from the corresponding authors on reasonable request.

Abbreviations

Adjusted odd ratio

Confidence interval

Blood pressure

Prince Sultan Medical City

primary health clinic

institution review board

Cerebrovascular accident

The World Health Organization

Al-Nozha MM, Abdullah M, Arafah MR, Khalil MZ, Khan NB, Al-Mazrou YY, et al. Hypertension in Saudi Arabia. Saudi Med J. 2007;28(1):77–84.

PubMed   Google Scholar  

Chobanian AV, Bakris GL, Black HR, et al. Prevention, detection, evaluation, and treatment of high blood pressure the seventh report of the joint National Committee on complete report. Natl High Blood Press Educ Progr. 2003;42(6):1206.

CAS   Google Scholar  

De Geest S, Sabaté E. Adherence to long-term therapies: Evidence for action. Eur J Cardiovasc Nurs. 2003;2:323.

Bramley TJ, Gerbino PP, Nightengale BS, Frech-Tamas F. Relationship of blood pressure control to adherence with antihypertensive monotherapy in 13 managed care organizations. J Manag Care Pharm. 2006;12(3):239–45.

Saeed AA, Al-Hamdan NA, Bahnassy AA, Abdalla AM, MAF A, Abuzaid LZ. Prevalence, awareness, treatment, and control of hypertension among Saudi adult population: A national survey. Int J Hypertens. 2011, 2011:174135 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21912737 . [cited 2020 May 4].

Elbur AI. Level of adherence to lifestyle changes and medications among male hypertensive patients in two hospitals in taif; kingdom of Saudi Arabia. Int J Pharm Pharm Sci. 2015;7(4):168–72.

Google Scholar  

Ramli A, Ahmad NS, Paraidathathu T. Medication adherence among hypertensive patients of primary health clinics in Malaysia. Patient Prefer Adherence. 2012;6:613–22.

PubMed   PubMed Central   Google Scholar  

Al-Sowielem LS, Elzubier AG. Compliance and knowledge of hypertensive patients attending PHC centres in Al-Khobar, Saudi Arabia. East Mediterr Heal J. 1998;4(2):301–7 Available from: https://apps.who.int/iris/handle/10665/118129 . [cited 2020 May 4].

Hadi N, Rostami-Gooran N. Determinant factors of medication compliance in hypertensive patients of Shiraz, Iran. Arch Iran Med. 2004;7(4):292–6 Available from: https://www.sid.ir/en/journal/ViewPaper.aspx? ID=13626. [cited 2020 May 4].

Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics-2012 update: a report from the American heart association. Circulation. 2012;3:125(1).

Goussous LS, Halasah NA, Halasa M. Non - Compliance to Antihypertensive Treatment among Patients Attending Prince Zaid Military Hospital. World Fam Med Journal/Middle East J Fam Med. 2015;13(1):15–9 Available from: https://platform.almanhal.com/Files/2/58839 . [cited 2020 May 4].

Article   Google Scholar  

Schoberberger R, Janda M, Pescosta W, Sonneck G. The COMpliance praxiS survey (COMPASS): a multidimensional instrument to monitor compliance for patients on antihypertensive medication. J Hum Hypertens. 2002;16(11):779–87.

Article   CAS   PubMed   Google Scholar  

Hyre AD, Krousel-Wood MA, Muntner P, Kawasaki L, KB DS. Prevalence and Predictors of Poor Antihypertensive Medication Adherence in an Urban Health Clinic Setting. J Clin Hypertens. 2007;9(3):179–86 Available from: http://doi.wiley.com/10.1111/j.1524-6175.2007.06372.x . [cited 2020 May 4].

Issa H, Banna A, Mohmed LH. Compliance and knowledge of hypertensive patients attending Shorsh Hospital in Kirkuk Governorate. Iraqi Postgrad Med J. 2010;9(2):145–50.

Klootwyk JM, Sanoski CA. Adherence and persistence in hypertension management. J Clin Outcomes Manag. 2011;18(8):351–8.

Karaeren H, Yokuşoǧlu M, Uzun Ş, Baysan O, Köz C, Kara B, et al. The effect of the content of the knowledge on adherence to medication in hypertensive patients. Anadolu Kardiyol Derg. 2009;9(3):183–8.

Ghembaza MA, Senoussaoui Y, Tani M, Meguenni K. Impact of patient knowledge of hypertension complications on adherence to antihypertensive therapy. Curr Hypertens Rev. 2014;10(1):41–8.

Elzubier AG, Al-Shahri MA. Drug control of hypertension in primary health care centers-registered patients, Al-khobar, saudi arabia. J Family Community Med. 1997;4(2):47–53 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23008573 . [cited 2020 May 4].

CAS   PubMed   PubMed Central   Google Scholar  

Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens. 2008;10(5):348–54.

González-fernández RA, Rivera M, Torres D, Quiles J, Jackson A. Usefulness of a systemic hypertension in-hospital educational program. Am J Cardiol. 1990;65(20):1384–6.

Article   PubMed   Google Scholar  

Brown J, Mellott S. The healthcare quality handbook : a professional resource and study guide; 2016. p. 439.

Mafutha GN, Wright SCD. Compliance or non-compliance of hypertensive adults to hypertension management at three primary healthcare day clinics in Tshwane. Curationis. 2013;36(1):E1–6.

Hussanin S, Boonshuyar C, Ekram A. Non-adherence to antihypertensive treatment in essential hypertensive patients in Rajshahi, Bangladesh. Anwer Khan Mod Med Coll J. 2011;2(1):9–14.

Al-Mehza AM, Al-Muhailije FA, Khalfan MM, Al-Yahya AA. Drug compliance among hypertensive patients; an area based study. Eur J Gen Med. 2009;6(1):6–10 Available from: http://www.ejgm.co.uk/download/drug-compliance-among-hypertensive-patients-an-area-based-study-6685.pdf . [cited 2020 May 4].

Busari OA, Olanrewaju TO, Desalu OO, Opadijo OG, Jimoh AK, Agboola SM, et al. Impact of Patients’ Knowledge, Attitude and Practices on Hypertension on Compliance with Antihypertensive Drugs in a Resource-poor Setting. TAF Prev Med Bull. 2010;9(2):87–92 Available from: www.korhek.org . [cited 2020 May 4].

Fitz-Simon N, Bennett K, Feely J. A review of studies of adherence with antihypertensive drugs using prescription databases. Ther Clin Risk Manag. 2005;1(2):93–106.

Article   PubMed   PubMed Central   Google Scholar  

Lee GKY, Wang HHX, Liu KQL, Cheung Y, Morisky DE, Wong MCS. Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky medication adherence scale. PLoS One. 2013;8(4):e62775.

Gonzalez J, Williams JW, Noël PH, Lee S. Adherence to mental health treatment in a primary care clinic. J Am Board Fam Pract. 2005;18(2):87–96.

Ambaw AD, Alemie GA, Wyohannes SM, Mengesha ZB. Adherence to antihypertensive treatment and associated factors among patients on follow up at University of Gondar Hospital, Northwest Ethiopia. BMC Public Health. 2012;12(1):282.

Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access [internet]. J Commun Health. 2013;38:976–93 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23543372 . [cited 2020 May 4].

Saudi Hypertension Management Society. Saudi Hypertension Guidelines. 2018.

Marcum ZA, Gellad WF. Medication Adherence to Multidrug Regimens. Clin Geriatr Med. 2012;28(2):287–300 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22500544 . [cited 2020 May 5].

Neutel JM, Smith DHG. Improving Patient Compliance: A Major Goal in the Management of Hypertension. J Clin Hypertens. 2003;5(2):127–32 Available from: http://doi.wiley.com/10.1111/j.1524-6175.2003.00495.x . [cited 2020 May 5].

Download references

Acknowledgments

Not applicable.

Author information

Authors and affiliations.

Family Medicine Department, Prince Sultan Military Medical City (PSMMC), Riyadh, Riyadh, Saudi Arabia

Fahad M. Algabbani

George Mason University, Fairfax, VA, USA

Aljoharah M. Algabbani

You can also search for this author in PubMed   Google Scholar

Contributions

The study design was conceptualized by FA and AA. Data collection was managed by FA and data analysis and interpretation were conducted by FA and AA. All authors participated in writing and editing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Fahad M. Algabbani .

Ethics declarations

Ethics approval and consent to participate.

Ethical approval was obtained from institution review board (IRB) of Prince Sultan Medical City. Before participants’ recruitment in the study, informed consent was obtained from all participants.

Consent for publication

Competing interests.

The authors have no competing interests to declare.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Algabbani, F.M., Algabbani, A.M. Treatment adherence among patients with hypertension: findings from a cross-sectional study. Clin Hypertens 26 , 18 (2020). https://doi.org/10.1186/s40885-020-00151-1

Download citation

Received : 21 May 2020

Accepted : 03 August 2020

Published : 15 September 2020

DOI : https://doi.org/10.1186/s40885-020-00151-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• High blood pressure
• Uncontrolled hypertension
• Nonadherence

Clinical Hypertension

ISSN: 2056-5909

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

Case Studies: BP Evaluation and Treatment in Patients with Prediabetes or Diabetes

—the new acc/aha blood pressure guidelines call for a more aggressive diagnostic and treatment approach in most situations..

By Kevin O. Hwang, MD, MPH, Associate Professor, McGovern Medical School, Houston, TX

The following case studies illustrate how the new ACC/AHA guideline specifies a shift in the definition of BP categories and treatment targets.

A 59-year-old man with type 2 diabetes presents with concerns about high blood pressure (BP). At a recent visit to his dentist he was told his BP was high. He was reclining in the dentist’s chair when his BP was taken, but he doesn’t remember the exact reading. He has no symptoms. He has never taken medications for high BP. He takes metformin for type 2 diabetes.

His BP is measured once at 146/95 mm Hg in the left arm while sitting. Physical exam is unremarkable except for obesity. EKG is unremarkable.

BP Measurement

Controlling BP in patients with diabetes reduces the risk of cardiovascular events, but the available data are not sufficient to classify this patient with respect to BP status. The reading taken while reclining in the dentist’s chair was likely inaccurate. A single reading in the medical clinic, even with correct technique, is not adequate for clinical decision-making because individual BP measurements vary in unpredictable or random ways.

The accuracy of BP measurement is affected by patient preparation and positioning, technique, and timing. Before the first reading, the patient should avoid smoking, caffeine, and exercise for at least 30 minutes and should sit quietly in a chair for at least 5 minutes with back supported and feet flat on the floor. An appropriately sized cuff should be placed on the bare upper arm and with the arm supported at heart level. For the first encounter, BP should be recorded in both arms. The arm with the higher reading should be used for subsequent measurements.

It is recommended that one use an average of 2 to 3 readings, separated by 1 to 2 minutes, obtained on 2 to 3 separate visits. Some of those readings should be performed outside of the clinical setting, either with home BP self-monitoring or 24-hour ambulatory BP monitoring, especially when confirming the diagnosis of sustained hypertension. Note that a clinic BP of 140/90 corresponds to home BP values of 135/85. Multiple BP readings in the clinic and at home allow for classification into one of the following categories.

The BP is measured in the office with the correct technique and timing referenced above. The patient is educated on how on to measure BP at home with a validated monitor. He should take at least 2 readings 1 minute apart in the morning and in the evening before supper (4 readings per day). The optimal schedule is to measure BP every day for a week before the next clinic visit, which is set for a month from now. Obtaining multiple clinic and home BP readings on multiple days will support a well-informed assessment of the patient’s BP status and subsequent treatment decisions.

A 62 year old African-American woman with prediabetes presents for her annual physical. She has no complaints. The average of 2 BP readings in her right arm is BP 143/88. Her physical exam is unremarkable except for obesity. She has no history of myocardial infarction, stroke, kidney disease, or heart failure. After the visit, she measures her BP at home and returns 1 month later. The average BP from multiple clinic and home readings is 138/86.

Her total cholesterol is 260 mg/dL, HDL 42 mg/dL, and LDL 165 mg/dL. She does not smoke.

Stage 1 Hypertension

Under the 2017 ACC/AHA guideline, she has stage 1 hypertension (HTN). This guideline uses a uniform BP definition for HTN without regard to patient age or comorbid illnesses, such as diabetes or chronic kidney disease.

In patients with stage 1 HTN and no known atherosclerotic cardiovascular disease (ASCVD) , the new guideline recommends treating with BP-lowering medications if the 10-year risk for ASCVD risk is 10% or greater. With input such as her age, gender, race, lipid profile, and other risk factors, the ACC/AHA Pooled Cohort Equations tool estimates her 10-year risk to be approximately 10.5%.

With stage 1 HTN and 10-year ASCVD risk of 10% or higher, she would benefit from a BP-lowering medication. Thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers are first-line agents for HTN because they reduce the risk of clinical events. In African-Americans, thiazide diuretics and calcium channel blockers are more effective for lowering BP and preventing cardiovascular events compared to ACE inhibitors or ARBs.

Patient-specific factors, such as age, comorbidities, concurrent medications, drug adherence, and out-of-pocket costs should be considered. Shared decision making should drive the ultimate choice of antihypertensive medication(s).

Nonpharmacologic strategies for prediabetes and HTN include dietary changes, physical activity, and weight loss. If clinically appropriate, she should also avoid agents which could elevate BP, such as NSAIDs, oral steroids, stimulants, and decongestants.

A goal BP of 130/80 is recommended. After starting the new BP medication, she should monitor BP at home and return to the clinic in 1 month. If the BP goal is not met at that time despite adherence to treatment, consideration should be given to intensifying treatment by increasing the dose of the first medication or adding a second agent.

A 63 year old man with type 2 diabetes has an average BP of 151/92 over the span of several weeks of measuring at home and in the clinic. He also has albuminuria.

Stage 2 Hypertension:

The BP treatment goal patients with diabetes and HTN is less than 130/80. While some patients can be effectively treated with a single agent, serious consideration should be given to starting with 2 drugs of different classes, especially if BP is more than 20/10 mm Hg above their BP target. Giving both medications as a fixed-dose combination may improve adherence.

In this man with diabetes and HTN, any of the first-line classes of antihypertensive agents (diuretics, ACE inhibitors, ARBs, and CCBs) would be reasonable choices. Given the presence of albuminuria, an ACE inhibitor or ARB would be beneficial for slowing progression of kidney disease. However, an ACE inhibitor and ARB should not be used simultaneously due to an increase in cardiovascular and renal risk observed in clinical trials.

He is started on a fixed-dose combination of an ACE-inhibitor and thiazide diuretic. He purchases a validated BP monitor which can transmit BP readings to his provider’s electronic health records system. Direct transmission of BP data to the provider has been shown to help patients achieve greater reductions in BP compared to self-monitoring without transmission of data. One month follow-up is recommended to determine if the treatment goal has been met.

Published: April 30, 2018

• 2. Final Recommendation Statement: High Blood Pressure in Adults: Screening. U.S. Preventive Services Task Force. September 2017.

More On This Topic

Does cabg owe its success more to sag--or to mag, dvt treatment: home versus hospital, perioperative thromboembolic complications predict long-term vte risk, coronary plaque in people with well-controlled hiv and low ascvd risk, poor neighborhood, poor mi outcome, stroke risk at age 66 to 74 years—with atrial fibrillation but without other risk factors, using cardiovascular biomarkers to diagnose type 2 mi: yea or nay, cardiac rehabilitation: outcomes in south asian patients.

Advertisement

Addressing Hypertension Outcomes Using Telehealth and Population Health Managers: Adaptations and Implementation Considerations

• Telemedicine and Technology (HB Bosworth, Section Editor)
• Open access
• Published: 10 May 2022
• Volume 24 , pages 267–284, ( 2022 )

Cite this article

You have full access to this open access article

• Connor Drake   ORCID: orcid.org/0000-0002-5393-6246 1 ,
• Allison A. Lewinski 2 , 5 ,
• Abigail Rader 1 ,
• Julie Schexnayder 2 ,
• Hayden B. Bosworth 1 , 2 , 3 , 4 , 5 ,
• Karen M. Goldstein 2 , 3 ,
• Jennifer Gierisch 1 , 2 , 3 ,
• Courtney White-Clark 2 ,
• Felicia McCant 2 &
• Leah L. Zullig 1 , 2  

4754 Accesses

6 Citations

3 Altmetric

Explore all metrics

Purpose of Review

There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control.

Recent Findings

Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery.

We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.

Similar content being viewed by others

Understanding heart failure; explaining telehealth – a hermeneutic systematic review.

Trisha Greenhalgh, Christine A’Court & Sara Shaw

Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review

Lina Naseralallah, Derek Stewart, … Vibhu Paudyal

Digital health technology and mobile devices for the management of diabetes mellitus: state of the art

Rongzi Shan, Sudipa Sarkar & Seth S. Martin

Avoid common mistakes on your manuscript.

Introduction

Hypertension (HTN) affects approximately 116 million adults in the USA [ 1 ]. It is one of the most prevalent contributors to cardiovascular disease, resulting in approximately 659,000 deaths in the USA each year [ 2 , 3 ]. While HTN alone is associated with cardiovascular disease and “all cause” mortality, its high co-occurrence with obesity, dyslipidemia, and diabetes makes HTN a persistent obstacle towards improved outcomes and equity and a significant driver of costs. When adjusting for age, the burden of HTN and related chronic conditions falls disproportionately on underserved communities [ 4 ]. As such, improving HTN outcomes among underserved communities is a priority area of focus for population health management efforts. Population health management is defined by its proactive focus on the health needs of a defined population or community, in contrast to exclusively reacting to individual level patient medical needs when they arise [ 5 , 6 ]. Within a population health paradigm, HTN management leverages technologies to identify and engage at-risk populations, thereby increasing reach and the potential for impact particularly among underserved communities.

There are multiple evidence-based strategies to manage HTN, including lifestyle modifications and medications. When HTN control is achieved, stroke is reduced 35–40%, myocardial infarction 20–25%, and heart failure over 50% [ 7 , 8 ]. However, uptake of lifestyle modifications and adherence to medications is suboptimal, so HTN control is often not achieved. In an analysis of 2015–2018 data, only 26.1% of adults with diagnosed HTN and prescribed medication achieved HTN control [ 9 ]. Patients’ long-term non-adherence rate to provider’s pharmacotherapy recommendations range from 50–70% [ 10 ]. Patient-level barriers associated with this lack of treatment and self-management include suboptimal adherence to medication or behavioral interventions and lack of knowledge and self-efficacy specific to managing HTN [ 11 , 12 ]. Provider-level barriers to evidence-based HTN management include insufficient time to spend with patients and clinical inertia which can result in failure to intensify treatments [ 13 , 14 , 15 ]. In fact, two-thirds of all suboptimal HTN treatment in the USA originates from inadequate provider treatment [ 16 ]. Provider challenges related to the complexity of polypharmacy is associated with suboptimal treatment adherence, which in turn leads to poor HTN control [ 17 ]. System level barriers such as a lack of care coordination, decision support, and access to BP monitoring/follow-up exacerbate existing challenges to HTN treatment [ 18 ]. The cumulative effect of barriers at the patient, provider, and system level is suboptimal HTN treatment. To be effective, population health management initiatives must recognize and work within and across each of these levels to achieve optimal blood pressure control targets.

In practice, population health management often refers to a range of health care services and analytics that support a coordinated and proactive approach to support improved outcomes for a community. In other words, the goal of population health management is to improve the health and well-being of a specific group of people or community [ 19 ••]. To this end, population health management uses multilevel approaches that require careful attention to the broader context of patient situations (e.g., low-income communities, limited transportation options, nutritious food availability, beliefs and norms, rurality) to better understand context-specific drivers of outcomes. By taking these multilevel factors into account, models of care can be more tailored and responsive.

We summarize emerging evidence to support HTN population health management as an effective responsive to the multi-level drivers of inequitable outcomes. First, we highlight several distinct yet complementary components of emerging best practices for designing HTN population health management initiatives: (1) population health management and the role of a population health manager; (2) team-based care; (3) telehealth modalities; and (4) the electronic health record (EHR). Second, we describe how the chronic care model can be used to guide the design of multi-level interventions. Third, we use the TEAM intervention as a case study to present implementation considerations and intervention adaptations to effectively manage HTN for a defined patient population. In describing the implementation processes, we emphasize practical considerations associated with intervention design, adaptation, scaling, and sustainability in real-world contexts. Finally, we provide perspective on future research directions and opportunities to support the translation of TEAM and HTN population health approaches like it into practice.

Components of Approaches to HTN Population Health Management

Population Health Management and the Role of a Population Health Manager

Population Health Management

Serxner et al. described the core components of population health management including attention to the full continuum of care, data sharing, and multidisciplinary care coordination [ 20 ]. Similarly, Matthews et al. focused on the shift of the role of health care systems from sporadic and episodic encounters to serve individuals in need of immediate care towards accountability for the health and well-being of an entire patient population [ 21 ]. When treatment interventions are organized and delivered through a population health management paradigm, interventions have the potential to lessen health disparities by proactively focusing on both unmet clinical and health-related social needs. Examples of population health management interventions to promote health equity include implementation of a system-wide screening intervention to decrease disparities in colorectal cancer screening rates [ 22 ], a care-management intervention bridging the transition from in-patient to out-patient mental health care to reduce readmissions of at-risk patients [ 23 ], and community partnerships and coordination to promote treatment adherence [ 24 , 25 •]. Additionally, interventions based on population health management are effective in achieving BP control for patients with uncontrolled HTN. For example, in a propensity score-matched cohort study of patients that received multi-disciplinary team case management to address HTN disparities in Baltimore, patients that completed all three sessions (39%) experienced reductions in systolic (9 mmHg) and diastolic blood pressure (4 mmHg) greater than matched controls with no disparities in these reductions among White and Black patients [ 26 •].

By taking a population health approach, we consider how inequities and social determinants of health shape why certain populations have differential health outcomes [ 27 ]. As population health management continues to gain prominence in the context of value-based care [ 28 ], it is critical to design HTN interventions and support translational efforts to ensure use in clinical practice. To translate evidence-based population health management interventions into practice, there are considerations that may impact the roles, responsibilities, composition, and staffing priorities of the care team and health system.

Population Health Manager

One emerging role that is central to population health management is that of the population health manager. A population health manager is a member of the health care team who uses population-level health data to identify unmet needs, intervene, and improve inequities and clinical outcomes among a defined community, usually within a shared geographic area. When embedded within the care team, the population health manager provides culturally appropriate counseling and gives support to patients related to their health self-management, navigating community resources or social services, and promoting treatment adherence [ 29 , 30 , 31 ]. Furthermore, a population health manager considers patient-level factors (e.g., self-efficacy, medical needs, social needs), clinic-level factors (e.g., specialty providers, community-based care, wrap-around service availability), and system-level factors (e.g., physical environment, eligibility and access to health and social services, and locally available resources), when developing health strategies [ 32 , 33 ]. Many times, nurses fill the role of population health managers as the role, purpose, and function of the population health manager complement the nurse’s training and approach to health and wellness.

Within the context of HTN, a population health manager would consider the patients’ cultural preferences and environment to tailor strategies for promoting self-management and medication and treatment adherence for HTN risk reduction. The reorientation of the health care workforce towards population health management, including the adoption of population health managers into care teams, represents an important opportunity to improve population health HTN outcomes and complement providers’ clinical management activities.

Team-Based Care

Team-based care is an essential component of a population health approach for HTN management. Team-based care models include personnel from both clinical specialties (e.g., social work, medicine, nursing) and non-clinical specialties (e.g., community health worker, data science, informatics) and are an evidence-based approach to improve health outcomes and quality of care, especially for those with chronic conditions. Effective team-based care models focus on disease management, provider coordination, performance measurement, the process of care delivery, and engaging the patient in decision making to promote self-management [ 34 ]. A team-based approach to HTN care is ideal but can be challenging in practice; for example, a patient’s primary care provider may not be able to easily view records and information generated by other providers. As a result, medication non-adherence or non-optimal prescribing patterns can result from lack of continuity of care due to barriers to information sharing [ 15 , 35 ]. A change in health behavior due to team-based care is particularly relevant to a condition such as HTN in which sustained treatment adherence and self-management are critical.

HTN team-based care interventions are associated with improved BP control and lower systolic and diastolic BP (especially when pharmacists and nurses are involved) and predict effectiveness of drugs [ 36 ••, 37 •]. Specifically, a 2009 meta-analysis by Carter at el. found that HTN interventions that emphasized integrating complementary roles and clinical specialties had large effect sizes on systolic blood pressure (SBP). For example, effective team-based care strategies included pharmacist treatment recommendations (− 9.30 mm Hg), nurse led interventions (− 4.80 mm Hg), and use of a treatment algorithm enabled through clinical informaticist support (− 4.00 mm Hg) [ 36 ••]. Team-based care not only has the potential to improve HTN outcomes, but also represents an extremely cost-effective approach to HTN management [ 38 •, 39 ]. A 2015 economic systematic review of team-based care interventions to control blood pressure found that they almost all were cost-effective at the most conservative threshold of $50,000 per quality-adjusted life-year (QALY) [ 40 ]. In addition, studies demonstrate that team-based care can increase patient satisfaction [ 40 ]. There is also an emerging evidence base that team-based care may be a mechanism for improving health equity. An analysis of 12 systematic reviews of the literature describing promising patterns and designs of interventions to reduce health disparities identified multidisciplinary team-based care interventions that were culturally tailored as a promising strategy [ 41 ].

Leveraging Telehealth Modalities

Effective population health management should consider strategic integration of existing technologies and digital platforms including telehealth to engage patients [ 42 •]. Telehealth is when a healthcare system exchanges medical information through electronic communication platforms to address a patient’s health [ 43 , 44 ]. Telehealth enabled communication can occur between clinicians, clinician and patient, and patient and mobile health technology to perform a variety of services including counseling, medication management, education, and monitoring. Telehealth occurs via two-way synchronous video or audio-only (e.g., by telephone) communication to complement or substitute in-person encounters as an efficient and convenient, accessible mechanism for chronic care delivery. Notably, the COVID-19 global pandemic and associated changes to telehealth reimbursement and regulatory policies have accelerated adoption of telehealth infrastructure across medical specialty service lines, a trend that continued after in-person visit volume returned to pre-pandemic levels [ 45 ].

There is an emerging evidence base describing effective telehealth approaches for patients with HTN and related chronic conditions. Specifically, telehealth technologies represent an important opportunity to improve HTN population health by addressing the multi-level drivers of blood pressure control. For example, in a 4-year randomized control trial, a nurse-led behavioral intervention administered via telephonic encounters showed an increase in HTN control by 13% when compared to usual care [ 46 ]. Another recent study showed that when used in conjunction with electronic health databases, telehealth interventions can improve quality of life, disease stability, and treatment compliance in elderly patients with co-morbid diseases [ 47 ]. Telehealth interventions are a promising mechanism for modifying patient non-adherence behaviors [ 48 , 49 ]. A systematic review of telehealth application included a broad range of clinical applications and showed that telehealth interventions as adjuncts to routine care produces positive outcomes and that the most pronounced benefits were for chronic conditions like HTN [ 45 ]. For example, telephone-based interventions improve treatment adherence and blood-pressure control in individuals with HTN [ 50 •]. Telehealth interventions also show promise for promoting health equity. When compared to usual care, nurse implemented telemedicine that combined behavioral and medical interventions improved mean systolic blood pressure, especially in African Americans [ 51 ]. Telephone-administered behavioral interventions have also shown success in HTN control and promise in Medicaid patients [ 52 , 53 •, 54 , 55 , 56 •, 57 , 58 ]. For example, in one 2011 study, implementing a telehealth HTN behavioral intervention resulted in treatment adherence increase from 55 to 77% in Medicaid patients [ 53 •]. One study implementing a telephone administered behavioral intervention at three primary care clinics versus nine usual care sites showed success in larger-scale implementation; however, there is still a gap between discovery and delivery. Despite evidence that these interventions can be effective in controlled research conditions, there is a need to better understand (i) what is necessary to introduce and sustain a novel intervention into routine clinical care and (ii) what aspects of the intervention are critical to preserve to produce the same results in “real-world” clinical and community settings [ 52 ]. As telehealth becomes a more common treatment intervention, health system-wide data for tailored scaling across a defined population is a critical need and implementation consideration [ 59 ].

The Role of the EHR

Effective and efficient HTN care models often feature the use of EHR technologies to identify patients, coordinate activities, and engage through behavioral interventions in a timely manner. In fact, emerging technologies related to telemonitoring’s capture and integration within the EHR may represent an important opportunity for the field to augment and synergize with team-based care [ 60 ••]. Thus, there is an important role for system-level investments in clinical information systems and technology infrastructure to facilitate HTN team-based care and population health management.

Population health management interventions that leverage the EHR can improve population health by identifying high risk patients. EHRs include physical assessments and medical histories of individual patients to assess cardiovascular risk and rising risk [ 61 ]. EHRs can be used to evaluate interventions and predict risk, especially when integrated with other sources including data on social determinants [ 56 •, 62 ]. For example, data obtained from EHRs can be used to predict development of HTN and coronary heart disease, or to track associations between hospitalizations and patient characteristics related to heart-failure [ 63 , 64 , 65 ]. Additionally, EHRs can be used to assess health disparities [ 66 ] and inform the development of interventions to improve both health equity and outcomes.

The use of EHRs to inform interventions has implications for the design of population health surveillance efforts. New York City created a system to track HTN prevalence using aggregate EHR data from a network of outpatient practices. This example represents an opportunity to leverage EHR infrastructures at the population level and use the EHR to go beyond syndromic surveillance and quality improvement at the individual and practice levels [ 67 , 68 ]. Similarly, when a health maintenance organization system implemented a population-based HTN management program, they were able to achieve above 80% blood pressure control across the population represented in the hypertension registry [ 69 •]. A key facet of the program was a comprehensive, EHR-based, HTN registry to enable customizable queries that informed prioritization of patient subgroups (e.g., individuals with poorly controlled hypertension, underserved communities) that would benefit from treatment intensification. This risk stratification is consistent with a review of HTN interventions that found the most effective approaches included population (e.g., clinic or panel-level review) rather than an exclusive focus on patient-level intervention [ 70 ]. Using EHRs to enable a HTN population program deployed in concert with a team-based telehealth approach is synergistic and facilitates response to patient, provider, and system level barriers to HTN management.

Applying the Chronic Care Model to Design HTN Population Health Management Approaches

A HTN intervention within a population health paradigm should include an inclusive approach which incorporates chronic care model (CCM) concepts, including self-management support, care coordination, enhanced clinical information systems (e.g., clinical registries and telehealth), and decision support [ 71 ]. Therefore, data-driven (e.g., EHR), team-coordinated, telehealth technologies and intervention strategies facilitated by a population health manager represent complementary approaches to advance HTN population health management. We conducted a narrative review to describe the evidence base of these synergistic strategies that fit seamlessly within a population health management care paradigm. Table 1 summarizes particularly relevant studies the describe the role of a population health manager and the use of team-based care, the EHR, and telehealth to better manage HTN.

Based on the range of system-level factors that impact HTN outcomes and access to care, telehealth and virtual care address system level barriers to care by facilitating improved access. However, system level factors and social determinants of health present unique challenges and opportunities for uptake. For example, there are concerns that telehealth technologies may impact health equity if uptake, particularly for synchronous audio–video technologies, is greater among wealthier, white, and younger patients [ 72 , 73 ]. Variation of telehealth use is due to multi-factorial drivers including differences in social determinants (e.g., access to a reliable internet connection, patient and provider preferences, technological literacy, condition complexity, and medical visit type) [ 74 , 75 , 76 ]. However, evidence from the VA, which serves a significant rural patient population, suggests that telephonic telehealth may be an effective mechanism for improving access to care for more remote, underserved communities [ 77 , 78 ]. While effective best practices for telehealth continue to emerge across the care continuum, there is a need to advance integration of telehealth approaches within a population health management paradigm (i.e., proactive, focused on a population and equity), requiring complementary team-based models of care and EHR-enabled identification and coordination. To better illustrate the intersection of telehealth and population health management, we present an evidence-based intervention called TEAM [ 79 ••].

Case Study: Team-Supported, EHR-Leveraged, Active Management (TEAM) Intervention

As the largest integrated health care system in the USA, the Veterans Affairs’ Veterans Health Administration (VHA) has a unique opportunity to manage HTN using a population health approach and presents an integrated care environment which allows for a successful intervention because of advancements in care coordination and management [ 71 ]. A population health approach in the context of the VHA includes leveraging a team of specialists drawing from the integrated system to work together. Care coordination is an especially critical consideration for rural communities that the VHA disproportionately serves, who face challenges associated with higher rates of HTN and inadequate local resources [ 81 ]. To address this challenge and integrate the aforementioned components of effective HTN population health management, we developed Team-supported, EHR-leveraged, Active Management (TEAM) based on stakeholder feedback using existing health care system employees, resources, and technological infrastructure.

TEAM leverages capabilities of an integrated health care system consistent with best practices for improving HTN population health outcomes. TEAM includes a targeted approach to a defined patient population using the electronic health record, a team-based approach featuring a nurse population health manager and leveraging existing telehealth infrastructure. TEAM consists of five core components: (1) identification of patients with uncontrolled HTN for enrollment according to criteria using an EHR-based query; (2) the patients received a CVD risk letter; (3) the population health manager created and entered a detailed care plan based on patient needs; (4) the primary care team ordered appropriate treatment; and (5) the population health manager reported patient progress [ 79 ••]. These complementary core components support Veterans in achieving optimal blood pressure control (Fig.  1 ). The pilot study of TEAM intervention demonstrated improved patient and system level outcomes, including improvements in HTN control [ 79 ••]. On the patient level, at 45 days following the TEAM intervention, 40% of patients had blood pressure measurements < 140/90 mm Hg. Compared with baseline (151/95 mm Hg), there was an average reduction of 11 mmHg and 5 mmHg, on systolic and diastolic blood pressure, respectively. This BP improvement was accomplished through improved patient engagement to adopt self-management behaviors and engage in productive interactions with their health care team. After the intervention, 61% of patients scheduled appointments, 83% attended scheduled appointments, and 62% contacted a healthcare provider either check their BP, change medications, or get a referral for a health service [ 79 ••]. The promising findings of the TEAM intervention are likely due to the complementary components based on emerging best practices in the HTN population health management literature; however, the integration of TEAM into real-world practices required modifications and adaptations to ensure fit.

TEAM intervention core components, including team-based care planning, population health manager, EHR support, telehealth outreach, and patient self-management and shared decision-making, represented as an interconnected cycle

TEAM Adaptations

Few research-developed interventions are adopted into real-world practice settings [ 82 ]. When they are, they are regularly modified or adapted to meet the needs of the target population or to match the clinical context. Often this process of modification is driven by constraints or contextual factors (e.g., staffing, cultural considerations, resource availability) and is done without a strategic or purposeful approach to ensure fidelity to the intervention’s original design. To support translational efforts, especially for multi-level interventions, it is critical to carefully and intentionally adapt interventions to match their intended context without compromising the essential elements that make it effective. Herein we describe TEAM intervention adaptation to better integrate in real-world clinical environments within diverse VA clinics. We used the Stirman et al.’s Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to analyze and organize TEAM intervention refinements, additions, and modifications [ 83 , 84 ]. By doing so, both practitioners and researchers can assess the rationale, timing, relationship to fidelity, and the impact of the modifications to ensure the intervention will retain its effectiveness.

FRAME classifies adaptations across different categories to inform reporting. These include (1) when and how the modification(s) were made, (2) whether it was planned/proactive (i.e., an adaptation) or unplanned/reactive, (3) the stakeholder that determined that the modification should be made, (4) what is modified, (5) the level of delivery that the modification is made (e.g., individual, cohort, practitioner, clinic, network, or system/community), (6) the nature of content-level modifications (e.g., substitution, addition, integrating other evidence based components), (7) the extent to which fidelity is preserved, and (8) the modification rationale (e.g., the intent or goal of the modification or the contextual implementation factors that the modification was made in response to).

We documented the adaptations and changes to the TEAM protocol by engaging with front-line stakeholders, investigators, and research staff. Once feedback had been collated, we organized and reported adaptations to intervention components consistent with FRAME. Adaptations were developed proactively and iteratively at a single site during a pilot phase to identify barriers to implementation and implementation strategies. We focused on adaptations across four core elements of the TEAM intervention: (i) identification and screening of eligible patients; (ii) recruitment and outreach; (iii) patient engagement and activation; (iv): EHR-enabled documentation and team-based care planning. The evaluation of modifications to improve fit with local practice patterns and capabilities can inform the design of implementation strategies and provide practical considerations for practitioners for integrating TEAM and evidence-based HTN population health management approaches like it (see Table 2 ). For example, we found that adaptations ranged from minor “tweaks” to facilitate adoption (e.g., minor changes to inclusion criteria to reach more patients or utilizing locally available technologies to promote communication and care planning) to more significant alterations of the intervention (e.g., removing medication adjustments as a component of the intervention). These data on implementation and adaptations were used to identify relevant and agreed upon implementation strategies to overcome anticipated implementation barriers as we implemented TEAM at additional subsequent VHA sites. By providing guidance and technical assistance on permissible adaptations that can be made without compromising intervention fidelity, translational efforts to integrate TEAM into real-world clinical settings can be better supported.

Implementation Considerations and Lessons Learned

Adaptations are a key concept in implementation to improve intervention fit or effectiveness in a specific context. The aforementioned modifications rarely exist within a vacuum and are often made in response to implementation factors. To highlight implementation factors associated with TEAM, we assessed implementation context based on the Consolidated Framework For Implementation Research (CFIR), a framework centered on (1) intervention characteristics, or attributes of TEAM that impact implementation success; (2) outer setting, or economic and social factors within the community and health system that affect implementation; (3) inner setting, or contextual factors within the health system and clinics that influence implementation; (4) individual characteristics of the individuals that use TEAM; and (5) implementation processes, or actions taken by individuals to implement [ 85 , 86 ]. The experience using a population health manager within a multi-level HTN population health management intervention requires attention to the implementation factors across domains captured by CFIR. In Table 3 , we summarize these lessons learned and map them to CFIR domains and constructs to illustrate the complex interplay between the intervention, context, and the dynamic processes, systems, and agents that can drive or inhibit implementation, for example, defining roles and performance metrics and establishing communication channels and protocols for team-based care.

HTN population health management is an important frontier for the field that requires adapting best practices within a population health paradigm consistent with the CCM. We describe relevant literature and discuss the resulting implications for staffing, organization of care, integration of technologies and analytics, and implementation by exploring promising, evidence-based components including leveraging the EHR, team-based care, telehealth, and novel care team composition (e.g., the role of a population health manager). These strategies and components are successful because they advance HTN care in a CCM consistent and organized way within a population health paradigm by being responsive to the multi-level drivers of poor HTN adherence and outcomes.

We use the TEAM intervention as an exemplar that has demonstrated improved patient and system level outcomes, including improvements in HTN control [ 79 ••]. Specifically, TEAM improved engagement and management in patients with high BP and led to improved clinical outcomes [ 79 ••]. We also explore the challenges to translating intervention components developed in a research context into routine care and the need for strategic and proactive adaptation. In doing so, we highlight the complex interplay and practical considerations of modifying an intervention to facilitate adoption balanced with the importance of maintaining fidelity to evidence-based components. These adaptations range from “tweaks” to substantive modifications and should be monitored carefully to ensure that effectiveness is not diminished. The experience with TEAM in the VA highlights the promise of translational efforts but should be interpreted with caution. As TEAM and interventions like it are moved outside of a VA institutional environment into community and other clinical contexts, further adaptation will be needed in response to dynamic factors including patient characteristics, data availability, and existing infrastructure.

Availability of Data and Material

Upon request from Dr. Bosworth, the project lead of TEAM.

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

Centers for Disease Control and Prevention (CDC). Facts about hypertension. US Department of Health and Human Services. 2020. https://www.cdc.gov/bloodpressure/facts.htm . Accessed 7 April 2021.

Kannel WB. Blood pressure as a cardiovascular risk factor. JAMA. 1996;275(20):1571. https://doi.org/10.1001/jama.1996.03530440051036 .

Article   CAS   PubMed   Google Scholar  

Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al. Heart disease and stroke statistics–2021 update: a report from the American Heart Association. Circulation. 2021;143:e254–743.

Article   Google Scholar  

Buttorff C, Ruder T, Bauman M. Multiple chronic conditions in the United States. Santa Monica, CA: Rand. 2017;10.

Bozkurt B, Aguilar D, Deswal A, Dunbar SB, Francis GS, Horwich T, et al. Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the American Heart Association. Circulation. 2016;134(23):535–78. https://doi.org/10.1161/CIR.0000000000000450 .

Long AN, Dagogo-Jack S. The comorbidities of diabetes and hypertension: mechanisms and approach to target organ protection. J Clin Hypertens. 2013;13(4):244–251. https://doi.org/10.1111/2Fj.1751-7176.2011.00434.x

Yoon PW, Gillespie CD, George MG, Wall HK, Centers for Disease C. Prevention Control of hypertension among adults--National Health and Nutrition Examination Survey, United States, 2005–2008. MMWR Morb Mortal Wkly Rep. 2012;61 Suppl:19–25. PMID: 22695459

Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists' Collaboration. Lancet. 2000;356(9246):1955–1964.

Ritchey MD, Gillespie C, Wozniak G, et al. Potential need for expanded pharmacologic treatment and lifestyle modification services under the 2017 ACC/AHA Hypertension Guideline. The J Clin Hyper. 2018;20(10):1377–91. https://doi.org/10.1111/jch.13364 .

Article   PubMed   PubMed Central   Google Scholar  

Adherence to long-term therapies. evidence for action. Geneva: World Health Org 2003.

Google Scholar  

Bosworth HB, Oddone EZ, Weinberger M. Patient treatment adherence: concepts, interventions, and measurement. Mahwah, NJ: Lawrence Erlbaum Asso 2006.

Book   Google Scholar  

Hong TB, Oddone EZ, Dudley TK, Bosworth HB. Medication barriers and anti-hypertensive medication adherence: the moderating role of locus of control. Psychol Health Med. 2006;11(1):20–8. https://doi.org/10.1080/14786430500228580 .

Article   PubMed   Google Scholar  

Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski VL, Egan BM. Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals. Hypertension. 2006;47(3):345–51. https://doi.org/10.1161/01.hyp.0000200702.76436.4b .

Schmittdiel JA, Uratsu CS, Karter AJ, et al. Why don’t diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification. J Gen Intern Med. 2008;23(5):588–594. https://doi.org/10.1007/2Fs11606-008-0554-8

Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119(23):3028–35. https://doi.org/10.1161/circulationaha.108.768986 .

Wang TJ, Vasan RS. Epidemiology of uncontrolled hypertension in the United States. Circulation. 2005;112(11):1651–62. https://doi.org/10.1161/circulationaha.104.490599 .

Egan BM, Zhao Y, Li J, et al. Prevalence of optimal treatment regimens in patients with apparent treatment-resistant hypertension based on office blood pressure in a community-based practice network. Hypertension. 2013;62(4):691–7. https://doi.org/10.1161/hypertensionaha.113.01448 .

Steinbrook R. Health care and the American Recovery and Reinvestment Act. N Engl J Med. 2009;360(11):1057–60. https://doi.org/10.1056/nejmp0900665 .

•• Steenkamer BM, Drewes HW, Heijink R, Baan CA, Struijs JN. Defining population health management: a scoping review of the literature. Popul Health Manag. 2017;20(1):74–85. https://doi.org/10.1089/pop.2015.0149 . A comprehensive definition of population health management.

Serxner S, Noeldner SP, Gold D. Best practices for an integrated population health management (PHM) program. Am J Health Promot 2006;20(5 suppl):1–10, iii. https://doi.org/10.4278/0890-1171-20.5.tahp-1

Matthews MB, Hodach R. Automation is key to managing a population’s health. Healthc Financ Manage. 2012;66(4):74–8 (PMID: 22523891).

PubMed   Google Scholar  

Berkowitz SA, Percac-Lima S, Ashburner JM, Chang Y, Zai AH, He W, et al. Building equity improvement into quality improvement: reducing socioeconomic disparities in colorectal cancer screening as part of population health management. J Gen Inter Med. 2015;30:942–9. https://doi.org/10.1007/s11606-015-3227-4 .

Hutchison SL, Flanagan JV, Karpov I, et al. Care management intervention to decrease psychiatric and substance use disorder readmissions in Medicaid-enrolled adults. J Behav Health Serv Res. https://doi.org/10.1007/s11414-018-9614-y

Jones LK, Greskovic G, Grassi DM, et al. Medication therapy disease management: Geisinger’s approach to population health management. Am J Health Syst Pharm. 2017;74:1422–35. https://doi.org/10.2146/ajhp161061 .

• Halladay JR, Donahue KE, Hinderliter AL, et al. The heart healthy lenoir project-an intervention to reduce disparities in hypertension control: study protocol. BMC Health Services Research. 2013;13(1). https://doi.org/10.1186/1472-6963-13-441 . An exemplar population health management intervention to improve hypertension outcomes for an underserved population.

• Hussain T, Franz W, Brown E, et al. The role of care management as a population health intervention to address disparities and control hypertension: a quasi-experimental observational study. Ethn Dis. 2016;26(3):285–294. Published 2016 Jul 21. https://doi.org/10.18865/ed.26.3.285 . An exemplar population health management intervention to improve hypertension outcomes for an underserved population.

Young TK. Population health: concepts and methods. 2 nd Ed. Oxford University Press; 2004.

Felt-Lisk S, Higgins T. Exploring the promise of population health management programs to improve health. Mathematica. 2001.

Brownstein JN, Chowdhury FM, Norris SL, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007;32(5):435–47. https://doi.org/10.1016/j.amepre.2007.01.011 .

Norris SL, Chowdhury FM, Van Le K, et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med. 2006;23(5):544–56. https://doi.org/10.1111/j.1464-5491.2006.01845.x .

Dolor RJ, Yancy WS Jr, Owen WF, et al. Hypertension Improvement Project (HIP): study protocol and implementation challenges. Trials. 2009;10:13. https://doi.org/10.1186/1745-6215-10-13 .

Radzyminski S. The concept of population health within the nursing profession. J Prof Nurs. 2007;23(1):37–46. https://doi.org/10.1016/j.profnurs.2006.10.004 .

Moore M, Peterson L, Coffman M, Jabbarpour Y. Care coordination and population management services are more prevalent in large practices and patient-centered medical homes. J Am Board Fam Med. 2016;29(6):652–3. https://doi.org/10.3122/jabfm.2016.06.160180 .

Goldberd DG, Beeson T, Kuzel AJ, Love LE, Carver MC. Team-based care: a critical element of primary care practice transformation. Popul Health Manag. 2013;16(3). https://doi.org/10.1089/pop.2012.0059

Flocke SA, Strange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract. 1997;45(2):129–35 (PMID: 9267371).

CAS   PubMed   Google Scholar  

•• Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169(19). https://doi.org/10.1001/archinternmed.2009.316 . A ground breaking systematic review and meta-analysis to evaluate team based care interventions’ impact on hypertension outcomes.

• Proia KK, Thota AB, Njie GJ, Finnie RKC, Hopkins DP, Mukhtar Q, et al. Preventive services task force, community. team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med. 2014;47(1):86–99. https://doi.org/10.1016/j.amepre.2014.03.004 . An exemplar population health management intervention that features team based care to improve hypertension outcomes.

• Jacob V, Chattopadhyay SK, Thota AB, Proia KK, Njie G, Hopkins DP, et al. Preventive Services Task Force, Community. Economics of team-based care in controlling blood pressure: a community guide systematic review. Am J Prev Med. 2015;49(5):772–783. https://doi.org/10.1016/j.amepre.2015.04.003 . A systematic review and cost-effectiveness analysis of team based care interventions to improve hypertension outcomes .

Wohler DM, Liaw W. Team-based primary care: opportunities and challenges. Starfield Summit; 2016.

Wen J, Schulman KA. Can team-based care improve patient satisfaction? A systematic review of randomized controlled trials. PLoS ONE. 2014;9(7): e100603. https://doi.org/10.1371/journal.pone.0100603 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med. 2012;27(8):992–1000. https://doi.org/10.1007/s11606-012-2082-9 .

• Milani RV, Lavie CJ, Bober RM, Milani AR, Ventura HO. Improving hypertension control and patient engagement using Digital Tools. Am J Med. 2017;130(1):14–20. https://doi.org/10.1016/j.amjmed.2016.07.029 . An exemplar population health management intervention that features digital medicine to improve hypertension outcomes.

Bingham JM, Black M, Anderson EJ, et al. Impact of telehealth interventions on medication adherence for patients with type 2 diabetes, hypertension, and/or dyslipidemia: a systematic review. Ann Pharmacother. 2021;55(5):637–49. https://doi.org/10.1177/1060028020950726 .

Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585–92. https://doi.org/10.1056/nejmsr1503323 .

Drake C, Lian T, Cameron B, Medynskaya K, Bosworth HB, Shah K. Understanding telemedicine’s “New normal”: variations in telemedicine use by Specialty Line and patient demographics. Telemedicine and e-Health. 2021. https://doi.org/10.1089/tmj.2021.0041 .

Bosworth H, Olsen MK, Dudley T, Orr M, Goldstein MK, Datta SK, et al. The Veterans’ Study to Improve The Control of Hypertension (V-STITCH): a patient and provider intervention to improve blood pressure control. In: 25th HSR&D National Meeting. Washington: DC; 2007. p. 15.

Noel HC, Vogel DC, Erdos JJ, Cornwall D, Levin F. Home telehealth reduces healthcare costs. Telemed J E Health. 2005;10(2)

Totten AM, Womack DM, Eden KB, et al. Telehealth: mapping the evidence for patient outcomes from systematic reviews. Agency for Healthcare Research and Quality (US), Rockville (MD); 2016. PMID: 27536752

Totten AM, Womack DM, Eden KB, et al. Agency for Healthcare Research and Quality; 2016.

• Friedman RH, Kazis LE, Smith MB, Stollerman J, Torgerson J, Carey K. A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens. 1996;9(4 Pt 1):285–92. https://doi.org/10.1016/0895-7061(95)00353-3 . An exemplar medication adherence intervention that features telehealth to improve hypertension outcomes.

Bosworth HB, Olsen MK, McCant F, Harrelson M, Gentry P, Rose C, et al. Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control. Am Heart J. 2007;153(6):918–24. https://doi.org/10.1016/j.ahj.2007.03.004 .

Bosworth HB, Almirall D, Weiner BJ, Maciejewski M, Kaufman MA, Powers BJ, et al. The implementation of a translational study involving a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study protocol (01295). Implement Sci. 2010;16(5):54. https://doi.org/10.1186/1748-5908-5-54 .

• Bosworth HB, DuBard CA, Ruppenkamp J, Trygstad T, Hewson DL, Jackson GL. Evaluation of a self-management implementation intervention to improve hypertension control among patients in Medicaid. Transl Behav Med. 2011;1(1):191–9. https://doi.org/10.1007/s13142-010-0007-x . An exemplar population health management intervention that features telehealth outreach across a statewide Medicaid population to improve hypertension outcomes.

Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone intervention for Blood Pressure Control: a patient-tailored multifactorial intervention. Patient Educ Couns. 2005;57(1):5–14. https://doi.org/10.1016/j.pec.2004.03.011 .

Bosworth HB, Olsen MK, Neary A, et al. Take control of your blood pressure (TCYB) study: a multifactorial tailored behavioral and educational intervention for achieving blood pressure control. Patient Educ and Couns. 2008;70(3):338–47. https://doi.org/10.1016/j.pec.2007.11.014 .

• Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control. Ann Intern Med. 2009;151(10):687. https://doi.org/10.7326/0000605-200911170-00148 . An exemplar population health management intervention that leveraged telehealth and remote monitoring to improve hypertension outcomes.

Bosworth HB, Powers BJ, Olsen MK, et al. Home blood pressure management and improved blood pressure control. Arch Intern Med. 2011;171(13):1173. https://doi.org/10.1001/archinternmed.2011.276 .

Bosworth HB, Olsen MK, Dudley T, et al. Patient education and provider decision support to control blood pressure in primary care: a cluster randomized trial. Am Heart J. 2009;157(3):450–6. https://doi.org/10.1016/j.ahj.2008.11.003 .

Abbott PA, Liu Y. A scoping review of telehealth. Yearb Med Inform. 2013;8:51–8 (PMID: 23974548).

•• Derington CG, King JB, Bryant KB, et al. Cost-effectiveness and challenges of implementing intensive blood pressure goals and team-based care. Current Hypertension Reports. 2019;21(12). https://doi.org/10.1007/s11906-019-0996-x . An overview of the cost-effectiveness and implementation of team-based care models to improve hypertension outcomes.

Häyrinen K, Saranto K, Nykänen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J Med Inform. 2008;77(5):291–304. https://doi.org/10.1016/j.ijmedinf.2007.09.001 .

Drake C, Lian T, Trogdon JG, et al. Evaluating the association of social needs assessment data with Cardiometabolic Health status in a federally qualified community health center patient population. BMC Cardiovascular Disorders. 2021;21(1). https://doi.org/10.1186/s12872-021-02149-5

Radhakrishnan K, Jacelon CS, Bigelow C, Roche J, Marquard J, Bowles KH. Use of a homecare electronic health record to find associations between patient characteristics and re-hospitalizations in patients with heart failure using telehealth. J Telemed Telecare. 2013;19(2):107–112. https://doi.org/10.1258/2Fjtt.2012.120509

Ye C, Fu T, Hao S, Zhang Y, Wang O, Jin B, et al. Prediction of incident hypertension within the next year: prospective study using statewide Electronic Health Records and machine learning. J Med Internet Res. 2018;20(1): e22. https://doi.org/10.2196/jmir.9268 .

Du Z, Yang Y, Zheng J, Li Q, Lin D, Li Y, et al. Accurate prediction of coronary heart disease for patients with hypertension from Electronic Health Records with big data and machine-learning methods: model development and performance evaluation. JMIR Med Inform. 2020;8(7): e17257. https://doi.org/10.2196/17257 .

Shuey MM, Gandelman JS, Chung CP, Nian H, Yu C, Denny JC, et al. Characteristics and treatment of African-American and European-American patients with resistant hypertension identified using the electronic health record in an academic health centre: a case−control study. BMJ Open. 2018;8: e021640. https://doi.org/10.1136/bmjopen-2018-021640 .

Newton-Dame R, McVeigh KH, Schreibstein L, et al. Design of the New York City macroscope: innovations in population health surveillance using electronic health records. EGEMS (Wash DC). 2016;4(1):1265. https://doi.org/10.13063/2327-9214.1265

Lu Y, Huang C, Mahajan S, et al. Leveraging the electronic health records for Population Health: a case study of patients with markedly elevated blood pressure. J Am Heart Asso. 2020;9(7). https://doi.org/10.1161/jaha.119.015033

• Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310(7):699. https://doi.org/10.1001/jama.2013.108769 . An exemplar population health management intervention that leveraged an electronic health record enabled registry to improve hypertension outcomes.

Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010. https://doi.org/10.1002/14651858.cd005182.pub4 .

Cordasco KM, Hynes DM, Mattocks KM, Bastian LA, Bosworth HB, Atkins D. Improving care coordination for veterans within VA and across Healthcare Systems. J Gen Intern Med. 2019;34(S1):1–3. https://doi.org/10.1007/s11606-019-04999-4 .

Jaffe DH, Lee L, Huynh S, Haskell TP. Health inequalities in the use of telehealth in the United States in the lens of COVID-19. Popul Health Manag. 2020;23:368–77.

Ye S, Kronish I, Fleck E, et al. Telemedicine expansion during the COVID-19 pandemic and the potential for technology-driven disparities. J Gen Intern Med. 2020;36:256–8.

Bauerly BC, McCord RF, Hulkower R, Pepin D. Broadband access as a public health issue: The role of law in expanding broadband access and connecting underserved communities for better health outcomes. J Law Med Ethics 2019;47(2_Suppl.):39–42.

Goodman CW, Brett AS. Accessibility of virtual visits for urgent care among us hospitals: a descriptive analysis. J Gen Intern Med 2020. [Epub ahead of print]. https://doi.org/10.1007/s11606-020-05888-x .

Donelan K, Barreto EA, Sossong S, et al. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care. 2019;25(1):40–4.

Stevenson L, Ball S, Haverhals LM, Aron DC, Lowery J. Evaluation of a national telemedicine initiative in the Veterans Health Administration: factors associated with successful implementation. J Telemed Telecare. 2018;24(3):168–78. https://doi.org/10.1177/1357633X16677676 .

Lum HD, et al. “Anywhere to anywhere: use of telehealth to increase health care access for older, rural veterans.” Public Policy & Aging Report 30.1 (2020); 12–18.

•• Jazowski SA, Bosworth HB, Goldstein KM, White-Clark C, McCant F, Gierisch JM, et al. Implementing a population health management intervention to control cardiovascular disease risk factors. J Gen Intern Med. 2020;35:1931–3. https://doi.org/10.1007/s11606-020-05679-4 . A population health management intervention that combines best practices related to telehealth, electronic health record capabilities, and team-based care to improve hypertension outcomes in a Veteran population.

• Mulrooney M, Smith M, Lewis K, et al. Practical implementation insights from 2 Population Health Pharmacist Project approaches to improve blood pressure control. J Am Pharm. 2022;62(1):270–80. https://doi.org/10.1016/j.japh.2021.07.012 . An exemplar population health management intervention that uses the electronic health record to identify hypertensive patients likely to disproportionately benefit from proactive outreach by population health pharmacists. Implementation considerations are presented and discussed.

Bain NSC, Campbell NC, Ritchie LD, Cassidy J. Striking the right balance in colorectal cancer care–a qualitative study of rural and urban patients. Fam Pract. 2002;19(4):369–74.

Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yearb Med Inform. 2000;09(01):65–70. https://doi.org/10.1055/s-0038-1637943 .

Stirman SW, Baumann AA, Miller CJ. The frame: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Science. 2019;14(1). https://doi.org/10.1186/s13012-019-0898-y

Stirman SW, Miller CJ, Toder J, Calloway A. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implement Sci. 2013;8:65. https://doi.org/10.1186/1748-5908-8-65 .

Drake C, Lewinski A, Zullig L. The Consolidated Framework for Implementation Research (CFIR). In. The International Encyclopedia of Health Communication: Wiley; 2021. In press. Accepted January 26, 2021.

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. https://doi.org/10.1186/1748-5908-4-50 .

Download references

The research reported in this publication was supported by Office of Rural Health Award grant #ORH 14379; Durham Center of Innovation to Accelerate Discovery and Practice Transformation grant #CIN 13–410; Department of Veterans Affairs Office of Academic Affiliations grant #TPH 21–000 (to AAL); VA HSR&D grants #08–027 (to HBB) and #18–234 (to AAL); and National Heart, Lung, and Blood Institute of the National Institutes of Health award number K12HL138030 (to CD).

Author information

Authors and affiliations.

Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA

Connor Drake, Abigail Rader, Hayden B. Bosworth, Jennifer Gierisch & Leah L. Zullig

Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA

Allison A. Lewinski, Julie Schexnayder, Hayden B. Bosworth, Karen M. Goldstein, Jennifer Gierisch, Courtney White-Clark, Felicia McCant & Leah L. Zullig

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA

Hayden B. Bosworth, Karen M. Goldstein & Jennifer Gierisch

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA

Hayden B. Bosworth

School of Nursing, Duke University, Durham, NC, USA

Allison A. Lewinski & Hayden B. Bosworth

You can also search for this author in PubMed   Google Scholar

Contributions

CD, LLZ, AAL, KMG, JS, and HBB contributed to the study conception, framing, and design. AAL, LLZ, KMG, FM, JG, and CW contributed to the data preparation and extraction, and CD, AAL, JS, KMG, AR, HBB, and LLZ contributed to data interpretation and narrative literature review. The first draft of the article was written by CD, AAL, and LLZ. All authors read and approved the final article.

Corresponding author

Correspondence to Connor Drake .

Ethics declarations

Ethical approval.

The study described has been approved by the appropriate ethics committee and has been performed in accordance with ethical standards from the 1964 Declaration of Helsinki and later amendments. All persons who participated in the study gave informed consent prior to consent and have had identifying information omitted.

Conflict of Interest

Dr. Drake reports receiving funds from ZealCare. Dr. Lewinski reports receiving funding from the PhRMA Foundation and Otsuka. Dr. Bosworth reports receiving research funds from Sanofi, Otsuka, Johnson and Johnson, Improved Patient Outcomes, Novo Nordisk, PhRMA Foundation as well as consulting funds from Walmart, Webmed, Sanofi, Otsuka, Abbott, and Novartis. Dr. Zullig reports receiving funding from the PhRMA Foundation and Proteus Digital Health as well as consulting funds from Novartis and Pfizer. The remaining authors have no competing interests to declare. The findings and conclusions in this document are those of the author(s) who are responsible for its contents and do not represent the views of the Department of Veterans Affairs, the US Government, or Duke University. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs or Duke University.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Telemedicine and Technology

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Drake, C., Lewinski, A.A., Rader, A. et al. Addressing Hypertension Outcomes Using Telehealth and Population Health Managers: Adaptations and Implementation Considerations. Curr Hypertens Rep 24 , 267–284 (2022). https://doi.org/10.1007/s11906-022-01193-6

Download citation

Accepted : 16 April 2022

Published : 10 May 2022

Issue Date : August 2022

DOI : https://doi.org/10.1007/s11906-022-01193-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Hypertension
• Population health management
• Implementation science
• Multidisciplinary care team
• Electronic health record
• Telemedicine
• Find a journal
• Publish with us
• Track your research

• Open access
• Published: 27 March 2024

Communication barriers faced by pharmacists when managing patients with hypertension in a primary care team: a qualitative study

• Reuben Tan 1 ,
• Ariffin Kawaja 2 ,
• Swee Phaik Ooi 2 &
• Chirk Jenn Ng 2 , 3  

BMC Primary Care volume  25 , Article number:  100 ( 2024 ) Cite this article

70 Accesses

5 Altmetric

Metrics details

As primary care pharmacists take on an increasingly important and collaborative role in managing patients with chronic diseases, communication barriers with patients and healthcare colleagues have emerged. This study aimed to explore the communication barriers faced by pharmacists when managing patients with hypertension in a primary care team.

Twelve pharmacists working in five government primary care clinics were interviewed by a researcher using a topic guide. The interviews were audio-recorded, transcribed verbatim and subjected to thematic analysis.

Pharmacists’ management of patients with hypertension was found to be affected by communication challenges at three different levels: between pharmacists and patients, pharmacists and physicians, and physicians and patients. Barriers to communication between pharmacists and patients include language barrier, physical disabilities, medication brand changes, and specific challenges faced during video consultations. Barriers to communication between pharmacists and physicians include lack of access to patient information across institutions on the electronic medical records (EMR), inadequate and inappropriate documentation by physicians, and disruptive and ineffective phone calls by pharmacists to physicians. Barriers to communication between physicians and patients had a spillover effect on pharmacists; these barriers included language barrier, patients not discussing medication nonadherence with physicians, and conflicting advice given by physicians and pharmacists.

Conclusions

The communication barriers pharmacists faced when managing patients with hypertension involved multiple stakeholders. Many of the challenges resulted in patients having difficulty understanding and adhering to their management plan. Effective interventions to foster stronger interprofessional relationships and create a conducive platform of communication should be developed to address these communication barriers.

Peer Review reports

Hypertension is on the rise in Singapore and across the world [ 1 , 2 ], and primary care pharmacists in Singapore play an important role in the management of patients with hypertension. The latest National Population Health Survey conducted in 2019/2020 found that 1 in 3 (35.5%) Singaporean adults (aged 18–74) has hypertension, of whom nearly half of them have never been diagnosed, and among those who have been diagnosed and are on treatment, 2 out of 3 are poorly controlled [ 2 ]. Despite the availability of effective blood pressure-lowering medications and the evidence of lifestyle modifications in reducing blood pressure, implementation of clinical evidence in real-world clinical practice remains challenging [ 3 , 4 ]. This poses a significant burden of disease and care, as hypertension, if uncontrolled, can result in complications such as coronary artery disease, stroke, and chronic kidney disease [ 5 ]. This will affect the quality of life of patients and their caregivers and impose a significant healthcare cost and burden on the health system [ 6 ].

Currently, most patients with hypertension in Singapore (84%) are managed in the primary care setting, with the remaining patients being managed at specialist outpatient clinics in hospitals. Most patients (50.5%) seek care at government primary-care clinics (or polyclinics), while 33.5% of patients seek care from over 2000 private general practitioners [ 2 ]. Singapore has 23 polyclinics, which are healthcare centres that provide subsidised primary care, including primary medical treatment, preventive healthcare, and health education [ 7 ]. Besides primary care physician consultations, polyclinics offer other services including in-house nursing care, pharmacies, medical social services, dietitian, physiotherapy, podiatry, basic clinical laboratory, diagnostic radiology, and dental services. Pharmacists in polyclinics take on many roles, including reviewing prescriptions, dispensing medications, providing professional advice to physicians and other healthcare professionals on matters relating to drug use and disease management, as well as providing medication counselling to patients. Beyond Singapore, the practice of pharmacists is evolving as more pharmacists become incorporated into primary care teams, with a transition from dispensing medications to playing a more collaborative and patient-centred role [ 8 ]. Furthermore, pharmacist interventions have been shown to improve blood pressure control [ 9 ].

The role that primary care pharmacists play often requires them to interact not only with patients but also with other healthcare professionals [ 10 ]. Studies have identified several challenges faced by pharmacists when interacting with their healthcare colleagues. One commonly faced barrier was “medical dominance”, as defined by the Health Sociology Review as the occurrence of physicians “exerting sovereign power over other professions such as nursing” [ 11 ], thus undermining and restricting the roles of pharmacists [ 12 ]. Lack of clarity regarding a pharmacist’s role and responsibilities by other healthcare professionals also led to underutilisation of their services [ 13 ]. Studies have also shown that some physicians show a lack of respect towards pharmacists, resulting in pharmacists avoiding interacting with physicians [ 14 , 15 ]. Often, even trying to reach physicians proved to be challenging for pharmacists [ 16 ].

The pharmacists in Singapore’s polyclinics work in dynamic multidisciplinary teams to deliver care for a large number of patients who come from diverse socioeconomic, cultural and language backgrounds. Pharmacists work in a setting where one pharmacist will interact with multiple physicians who each have different communication and documentation styles. Furthermore, less than half of Singapore’s population (48.3%) uses English as their most frequently spoken language, and many other languages are spoken in this multiracial country, including Mandarin, Chinese dialects, Malay, Tamil, and other languages [ 17 ]. However, very few studies have been conducted locally to explore the communication challenges faced by primary care pharmacists in managing patients with hypertension.

We conducted a qualitative study exploring challenges faced by pharmacists when managing patients with hypertension in a Singapore public primary healthcare setting. ‘Communication barriers’ emerged as the main overarching theme. Therefore, this paper aimed to explore the communication barriers faced by primary care pharmacists when managing patients with hypertension in Singapore. By identifying these barriers, interventions can be developed to fill the gaps and address the unmet needs. The findings will be relevant to pharmacists who work in a team and manage patients with diverse backgrounds and to decision makers who are planning for healthcare interventions to improve hypertension care.

Study design

This study utilised a qualitative methodology consisting of individual in-depth interviews (IDIs), as it allowed us to inquire and delve into the views and experiences of primary care pharmacists concerning the management of patients with hypertension as encountered in their local practices [ 18 ].

The public healthcare system in Singapore is grouped into three clusters based on geographical location, with SingHealth Polyclinics managing patients in the eastern region of Singapore [ 19 ]. The study was conducted among primary care pharmacists involved in managing patients with hypertension across five SingHealth Polyclinics in Singapore. The five selected Polyclinics were distributed across various locations in the eastern region of Singapore and had different patient population profiles (age, socioeconomic status, education level and health literacy). Care was also taken to ensure that a spectrum of practice experience was represented.

In the polyclinics, most of the patients seen by pharmacists are above 64 years old, Mandarin speaking, and taking five medications on average. Polyclinic patients can consult pharmacists for a “medication review”. Patients are identified for medication review via two channels. Patients with medication-related issue(s) can be referred by a physician in the polyclinic, subject to the physician’s clinical discretion. Alternatively, patients who had not been referred by a physician for medication review, but are collecting their medications at the pharmacy counter, can be assessed by the dispensing pharmacist to have medication-related issue(s) and can receive the review service, subject to the patient’s consent. Each medication review session may take about 20 to 30 min, depending on the complexity of the case. The medication review process involves the evaluation of therapeutic efficacy of each drug, unmet therapeutic needs and the progress of the condition being treated. Other areas such as patient’s compliance, understanding of their conditions/drug treatments, correct administration techniques, storage conditions, etc., are assessed and reinforced where necessary. Actual and potential adverse effects, interactions (e.g. drug-drug, drug-food and drug-herb) are also highlighted. Medication review sessions are not disease-specific but tailored to each individual patient. For example, a patient with hypertension and diabetes mellitus will be reviewed for both conditions, and not just for hypertension. Should any medication-related issue be identified, the pharmacist will discuss a proposed action plan with the patient, and the prescriber if required. Where appropriate, the pharmacist will make a telephone call to the patient two weeks after the medication review session to evaluate the outcome of the action plan and arrange for the date of the next medication review session.

Participants, recruitment, sampling

We identified pharmacists at SingHealth Polyclinics who were involved in the care of patients with hypertension for at least six months. We purposively sampled pharmacists of different levels of seniority with varying years of experience practising in primary care. In addition, a pattern of snowball sampling developed as the participants named other pharmacists whom they felt would provide additional insights. Sample size was determined by data saturation whereby interviews were stopped when no new ‘views’, ‘experiences’, or ‘challenges’ emerged from the interviews and data analysis.

Data collection

The researchers of this study are RT, NCJ, AK and OSP. RT is a medical student; NCJ is a professor and clinician who specialises in family medicine; AK is a research fellow with a PhD degree in health communication; and OSP is a senior pharmacist working in a SingHealth Polyclinic.

Before commencing the IDIs, an interview topic guide was developed based on a literature review, clinical knowledge and research experience (Table  1 ). All interviews were carried out by NCJ, who had 20 years of experience conducting qualitative research. We avoided, whenever possible, selecting participants who were close acquaintances or colleagues of NCJ to minimise potential participant response bias. Prior to the interviews, the researchers gave the study information sheet and explained to the participants the aims of the study and the research method before informed consent was obtained from the participants. During the interviews, RT took detailed field notes that were used as discussion and comparison pointers with NCJ after the interviews, as well as for data analysis later. No repeat interviews were conducted. From March to October 2022, twelve 40–60 min IDIs were conducted. Data collection was stopped when data saturation had been reached. All IDIs were audio-recorded and transcribed verbatim, after which they were checked for accuracy and used as data for analysis.

Data analysis

After transcription and checking, the transcripts were imported into NVivo computer-assisted qualitative data analysis software for data management and thematic analysis. Inductive coding was then performed. Initially, two researchers each analysed one transcript independently. Codes (short phrase labels) were assigned to specific data sections that represented their significance (open coding). Subsequently, the researchers used their developed codes to code one more transcript each. The coding was then compared for inter-researcher consistency. Any differences were resolved by discussion until an agreement was reached on the list of codes. This list was then reviewed, and the codes were grouped together to form categories (axial coding). These categories were further reviewed in terms of relation, and underlying themes were created to reflect the meaning of the data. This coding framework was then used to code data from the remaining transcripts [ 20 ].

The remaining transcripts were distributed among three researchers (RT, NCJ, AK) and coded individually. New codes that emerged during analysis were added to the list upon consultation with the other researchers, while those that were not relevant were removed. The coding framework was continually relooked, and codes were rearranged into different or new categories as deemed appropriate through discussion among the researchers. In alignment with the comparative case approach, which used assorted forms of data [ 21 ], field notes taken during the interviews were also reviewed and included in the analysis process to help in comprehension and clarification of the data.

Data analysis was conducted from both clinical (RT and NCJ) and nonclinical (AK) perspectives. Although member checking was not conducted, our findings were presented to the fourth researcher (OSP) for review. OSP, who is a primary care pharmacist, checked and critiqued the analysis. Her feedback was subsequently used to revise the interpretation of the data. To improve the credibility of the analysis, the research team caried out regular reflection and discussion on potential biases that the researchers might harbour due to their backgrounds.

A total of 12 pharmacists participated in the study. Table 2 shows the participants’ demographic data.

The initial research question was to broadly explore the challenges and barriers faced by primary care pharmacists in the management of patients with hypertension. However, one recurrent theme emerged very strongly across all five polyclinics: communication.

With different stakeholders involved in the management of patients with hypertension, pharmacists were affected by communication challenges at three different levels: between pharmacists and patients, pharmacists and physicians, and physicians and patients. Figure  1 illustrates the barriers that surfaced at each interaction.

Communication barriers faced by primary care pharmacists in the management of patients with hypertension

Between pharmacists and patients

Pharmacists interacted with patients in the setting of medication review, dispensing, counselling, and reconciliation. Challenges emerged during these interactions that impacted the pharmacist’s management of patients with hypertension.

Language barrier

Language was a commonly raised factor. As a multiracial society, Singapore is home to many different ethnicities that speak varying languages; hence, language barriers emerged between pharmacy staff and patients, and this affected their ability to counsel patients appropriately. As put across by one pharmacist,

“Because many times they (patients) will tell us things like, ‘Oh, because when I got the medicine, I got it from a Malay speaking staff and I’m a Chinese and I don’t understand their English’” - Pharmacist with 15 years’ experience, Polyclinic C4

One pharmacist also pointed out that pharmacy staff would turn to other staff in the polyclinic to help with translation. This highlighted the issue of accuracy of translation, as medical and drug-related counselling has to be as accurate as possible to prevent medication errors and patient misconceptions.

“For example, we only have one or two Tamil-speaking staff; if this one patient only speaks Tamil, we may actually approach cross-domain staff who are Tamil-speaking to help us with the translation. However, we have to be more careful, because sometimes when they help us to translate, we do not know whether they actually translated it correctly or not.” - Pharmacist with 15 years’ experience, Polyclinic C2

Patients with physical disabilities

Many pharmacists mentioned that a number of patients with hypertension they encountered had disabilities that made communication more challenging. Deficits in patients’ memory, hearing, and vision caused patient counselling to become more time-consuming and at times ineffective.

“I would say it happens mainly to the very old elderly or maybe they might have Alzheimer’s or dementia or poor memory. That kind of patient, we will need more time. They tend to forget what the physician said, so they need more time to counsel.” - Pharmacist with 2 years’ experience, Polyclinic C1

“However, there can be patients who wear hearing aids; they may not be able to hear us properly. So I tend to write (the instructions) for them, if there’s a need to.” - Pharmacist with 2 years’ experience, Polyclinic C2

Medication brand changes

According to the pharmacists, medication brand changes were a common occurrence that made communication with patients even more arduous. Owing to polyclinic policy and partially due to supply chain disruptions during the COVID-19 pandemic, medications stocked in the pharmacy underwent brand changes regularly. When asked how frequently these medication brand changes occurred, one pharmacist replied,

“It can be every few months, every 3-4 months.” - Pharmacist with 27 years’ experience, Polyclinic C5

The participants reported that with every change in medication brand, they would have to spend more time devising methods to communicate the brand change to patients clearly and took longer for patient counselling as well. Given the already existing time constraint, frequent medication brand changes proved to be very challenging. One pharmacist remarked that they had to perform the following additional tasks with every medication brand change:

“So in our clinic, actually we print out a list of new drugs with their drug images and we show the patient, ‘this is the new drug you’re going to take, and the old one looks like this, the new drug looks like this, they’re different.’ If the patient does not understand, we ask them to take a picture, then go back, tell your children that these are different and so on. In addition, then occasionally, we will write for them: ‘This is new.’ And for medications that are new and we know patients will get confused very easily, we will put a label, we will say: ‘this is a change in packaging’ on the label so that whoever is handling that medication for the patients actually know that this medication is a new packaging.” - Pharmacist with 35 years’ experience, Polyclinic C5

As put across by another pharmacist,

“Oh, we will definitely have to spend a longer time, but there’s no other way.” - Pharmacist with 27 years’ experience, Polyclinic C5

Even after all these additional efforts put in by the pharmacists, patients would still be confused by medication brand changes. This negated the pharmacists’ previous efforts, affected patient nonadherence, and further increased the workload for the pharmacists and physicians who had to re-explain the brand changes.

“However, sometimes even though we do the counselling and put the ‘change in brand’ sticker, patients are still a bit dubious if they forget about the verbal counselling part. Upon going home, they say: ‘What is this sticker for?’ If they are illiterate, they do not understand the languages that is pasted on the sticker itself, so they will actually just leave the whole pack of medications there and they don’t take them. They will wait until the next visit when they come back and show it to the physician, ‘oh this one I did not take because I do not know what it is for.’” - Pharmacist with 15 years’ experience, Polyclinic C2

Use of video consultation

Video consultations are becoming increasingly popular in Singapore, but pharmacists also raised unique barriers that emerged from them. It was noted that many patients struggled with the usage of technology required for video consultations and that communication over a virtual means was more challenging than face-to-face consultations.

“We have to be a bit more thorough to ensure that they actually capture the information, especially if there’re changes to the medicines itself. So we may take more time for video consult compared to the usual face-to-face consult.” - Pharmacist with 2 years’ experience, Polyclinic C2 

“They (patients) are not so IT-savvy and they prefer not to use the V-con (video consultation) because they do not know how to use it. In addition, they do not want to trouble their caregivers, or their family members to help them with the setting up and things like that.” - Pharmacist with 15 years’ experience, Polyclinic C2

Between pharmacists and physicians

The pharmacists interacted with physicians regularly when managing patients with hypertension; this occurred in both directions, either from physicians to pharmacists or from pharmacists to physicians.

From physicians to pharmacists

When physicians made prescriptions or referred patients to pharmacists for medication counselling or reconciliation, they communicated this information to the pharmacists via documentation on electronic medical records (EMRs). Barriers arose from this mode of communication in two ways: lack of EMR integration across institutions and inadequate and inappropriate documentation.

Lack of access to patient medication information across institutions

Currently, in Singapore, different public healthcare clusters utilise different EMR platforms. The pharmacists highlighted that they encountered difficulty trying to harmonise a patient’s medications across different healthcare institutions due to the lack of integration of EMRs. When looking for existing or new prescriptions from physicians in other healthcare clusters, pharmacists had to access NEHR (National Electronic Health Record Singapore), which is a completely different portal from SingHealth’s in-house EMR platform.

“SCM is Singhealth cluster’s EMR platform. Then, when you want to find information from other health clusters, you cannot get the information. I mean when patient tell you ‘I recently visited Tan Tock Seng Hospital (TTSH), Khoo Teck Puat Hospital (KTPH)’ OK, you look into NEHR, you see maybe TTSH’s records there, NHG’s (Healthcare group under which TTSH and KTPH fall) records; useful, but still not fully encompassing all the records in Singapore. KTPH I think it uses a different system again that may not even file their medication list.” - Pharmacist with 10 years’ experience, Polyclinic C3

Inadequate and inappropriate documentation by physicians

After making changes or cancellations of medications, some physicians did not document these changes clearly on the EMR. This made it challenging for pharmacists, as they needed to verify the new list of medications or dosages by calling the physicians; this delayed the process of medication review and dispensing.

“Because some of the hospitals’ discharge summaries, especially for those patients who were recently hospitalised, they do not tend to indicate the medication changes. Therefore, it is difficult for us to verify whether the medicine should be continued or discontinued. So if there’s no proper indications, it is a bit hard for us to decide. So we may take more time to actually go through the records.” - Pharmacist with 2 years’ experience, Polyclinic C2

Beyond delaying medication review and dispensing, this inadequate documentation also led to conflicting advice given to the patient by the pharmacist and the physician.

“Because sometimes there might be a lapse, like for example, the physician told the patient this thing, then after when we counsel the medication to them then they will say but just now the physician said otherwise. However, the physician did not document this information in the clinical documents. Therefore, when I checked as a pharmacist, there was no mention anything like to stop for one day, for example.” - Pharmacist with 2 years’ experience, Polyclinic C1

In addition to inadequate documentation, the physicians sometimes made mistakes in their documentation on the EMR; this added to the pharmacists’ workload and impacted their roles in medication counselling and dispensing. For instance, some physicians inappropriately documented that their patients needed medication counselling due to their practice of copying and pasting from previous medication instructions in the EMR. This resulted in pharmacists having to routinely reassess their referred patients for the need for medication counselling.

“We will not conduct medication counselling to all the patients who are referred by physicians - we will assess. If let’s say there is no change, no new issue, then we will still send back to our PT (pharmacy technician) to dispense. (These inappropriate documentations arise as) Sometimes they (the physicians) forget, they just copy from the previous (entry). So the previous instructions, they forget to delete.” - Pharmacist with 12 years’ experience, Polyclinic C1

From pharmacists to physicians

Phone calls are disruptive and ineffective.

In the polyclinic, the pharmacist carries out an ‘intervention’ when they identify an error in the physician’s prescription. The pharmacists would contact and clarify with the physicians before making the appropriate changes; this is often done via a telephone call. The participants expressed that the phone calls frequently disrupted the physician’s consultation with a patient; this resulted in the physician’s delay in picking up the call or acting on the prescription error. With such delays, patients experienced longer waiting times and developed greater dissatisfaction. From the patient’s perspective, the pharmacy staff kept them from leaving the clinic. Therefore, pharmacy staff received the brunt of patient complaints instead of physicians.

“Because sometimes the physicians are seeing patients when the pharmacist calls for intervention. So it may take some time for us to get through to the physicians.” - Pharmacist with 2 years’ experience, Polyclinic C2

“Because we are the end point, patients will usually tend to blame us (for the delay). Therefore, our colleagues will feel down, and it may affect our pharmacy staff morale.” - Pharmacist with 2 years’ experience, Polyclinic C1

“Sometimes it can be stressful if the patient is in a rush. They’re pressing for an answer or they might even say, ‘You do not have to check, you just give me the medicine. I know what to do.’ And it is definitely not safe.” - Pharmacist with 5 years’ experience, Polyclinic C4

Continual disruptions to physicians’ consultations affected the relationship between pharmacists and physicians. This was perceived to be a pertinent problem in a setting where teamwork is essential for a multidisciplinary team to treat patients with hypertension.

“Even though how busy you (physicians) are, try to understand that we (pharmacists) actually do not call you (physicians) for the sake of calling. We do not want to disturb anybody, actually we don’t want to call physicians, we hate to call physicians. [laughter] However, because we have a reason to call you, so maybe just be nicer, try to understand us, why we actually call you.” - Pharmacist with 27 years’ experience, Polyclinic C5

Between physicians and patients

The pharmacists highlighted that they were also impacted by the barriers that emerged from communication between physicians and patients. These manifested in a ‘spill-over’ effect, where issues arising from communication between physicians and patients ultimately affected the communication between pharmacists and patients.

Pharmacists had to conduct more patient counselling if language barriers during physician‒patient consultations left gaps in the patient’s knowledge. While some pharmacists saw this as part of their role in the multidisciplinary team, others viewed it as an additional burden that added to their already heavy workload. As one pharmacist pointed out,

“Like a Chinese patient sees an Indian physician, for example. There is a language barrier; they don’t understand, they couldn’t request for a Chinese physician and so they may not understand what the physician is trying to say. In the end, they come to the pharmacy, and they found out they are getting one additional medicine. They will ask ‘why am I taking a new medicine?’” -Pharmacist with 2 years’ experience, Polyclinic C1

Patients did not discuss medication nonadherence with physicians

Similarly, when physicians were unable to pick up medication nonadherence, there was an impact on the pharmacist’s workload and decision making. On top of their existing workload, pharmacists had to elicit the reasons for nonadherence, revert to the physician for discussion regarding management options, and advise patients on the importance of adherence.

“When the patient actually tells us that oh, actually, these medications I am not taking at all. Then, I say, you did not tell the physician in the consult room? No, I did not tell the physician. Then, we need to communicate to the physicians. Then, we have to reinforce again that no you cannot self-titrate or self-adjust your dose.” -Pharmacist with 15 years’ experience, Polyclinic C2

“I’m not sure what happened there in the consultation room. Sometimes they are not so forthcoming. Yeah, so when they come down to the pharmacy, then they tell us there are other problems which they did not tell the physician. These medications could be expensive, he cannot afford or he thinks that his conditions are controlled. So we will document on the thing. We will also discuss this with the physician.” - Pharmacist with 35 years’ experience, Polyclinic C5

Conflicting advice given by physicians

When pharmacists communicated with patients, another barrier emerged when conflicting advice had been given to the patient by the physician. This led to patients becoming nonreceptive to pharmacists’ counselling or even distrusting them.

“Sometimes it’s just a very simple thing like whether this medication can be taken in the morning or night. Just a very simple question. Maybe the physicians did mention it’s better to take at night. Then when they come to me, maybe due to the compliance issue, I would suggest that this medication actually can be taken in the morning together with as your other medication because they tend to forget to take it at night. So for them, they will like, ‘No, the physician says must take at night’. So yes there is some argument there.” - Pharmacist with 12 years’ experience, Polyclinic C1

On top of this, many pharmacists expressed that patients trusted physicians more than pharmacists. This compounded the effect of conflicting advice, with patients becoming shut-off to pharmacists instead of considering the advice given.

“It is not really whether we are saying the right thing, we’re not saying on the same page and patients feel the difference. Patients think ‘Wow you’re telling me one thing, the physician is telling me another thing, you being the pharmacists, I think you’re not good enough to tell me what I should do.’” - Pharmacist with 35 years’ experience, Polyclinic C5

This study uncovered the barriers primary care pharmacists in Singapore face in the management of patients with hypertension, with a focus on the challenges arising from communication and documentation. The findings highlighted that pharmacists face difficulties in communicating with both patients and physicians and that physician‒patient communication also has an effect on pharmacists’ management. Team-based care is a promising advancement that taps into the expertise of various healthcare professionals to better control patients’ hypertension [ 22 ]. However, working in a team requires good communication between all parties, and this study highlighted several gaps in communication that need to be addressed.

This study identified language as a pertinent barrier that hindered effective communication with and management of patients with hypertension faced by pharmacists. With less than half of Singapore’s population (48.3%) using English as their most frequently spoken language, it is expected that healthcare professionals will meet patients with whom they do not share a spoken language. A study performed among patients in Malaysia, a neighbouring country that also has a multiracial population, reported that nearly all participants felt that the way to improve patient‒physician communication was for physicians to have the capability to speak the local languages [ 23 ]. The impact of language barriers has been well documented and includes reducing both patients’ and healthcare professionals’ satisfaction, decreasing the quality of healthcare provided and patient safety, and increasing waiting times for patients while affecting the workflow for healthcare professionals [ 24 , 25 , 26 ]. When a healthcare professional and patient lack a common language, initiating the process of shared decision-making, exchanging accurate information, and presenting treatment options can become exceedingly challenging [ 27 ].

This study also surfaced the impact of medication brand changes on pharmacists’ management of patients with hypertension. Participants mentioned that due to global supply chain disruptions during the COVID-19 pandemic, the procurement of medications proved to be more challenging, and frequent medication brand changes resulted. However, even after the COVID-19 pandemic, many participants felt that medication brand changes were still a regular occurrence, with some participants pointing to fair trade policies as a cause. Existing interventions for each medication brand change were reported as too time-consuming and ineffective, with many patients still being confused about the changes. There have been few studies on this topic; one study conducted in Sweden [ 28 ] found similar challenges faced by pharmacists in terms of generic drug substitution. The study reported that many pharmacists were concerned that their patients would not understand the medication substitutions, leading to disruption of treatment or double medication. This suggests that the challenges faced regarding medication brand changes are widely held and that interventions should be devised to counter this pertinent problem. The Swedish study further surfaced that elderly individuals, who often face a higher degree of polypharmacy (concurrent use of multiple medications commonly defined as five or more), can be a particularly vulnerable group. As Singapore faces an ageing population and with most patients taking chronic hypertension medications being elderly, more emphasis should be placed on addressing the barriers created by frequent medication brand changes. Furthermore, the participants in the Swedish study expressed doubts regarding the actual long-term cost savings for society that are expected from drug brand substitutions. They raised concerns that any potential savings could be offset by the overall rise in medical expenses caused by decreased adherence to medications and the heightened confusion experienced by patients. This was similarly raised in our study, where many pharmacists expressed that even after spending more time and resources trying to help patients understand the medication brand changes, many patients would still be confused. This resulted in decreased medication adherence and increased workload for pharmacists and physicians, who had to perform extensive medication reconciliation and counselling in subsequent clinic follow-ups.

This study also raised certain barriers in communication between pharmacists and physicians, which posed challenges in managing patients with hypertension by pharmacists. One commonly identified barrier was the difficulty pharmacists faced in reaching physicians. Studies conducted in Canada and the United States also pointed out the struggles pharmacists faced in communicating directly with primary care physicians [ 16 , 29 ]. Notably, many of the pharmacists there felt that a main barrier to communication was the fact that they were not located in the same building as the physicians. The pharmacists from these studies postulated that working in the same physical location would greatly improve communication between physicians and pharmacists.

In Singapore’s polyclinics, physicians and pharmacists work in the same polyclinic, and yet all the participants in our study agreed that getting through to physicians proved to be challenging. Working in the same clinic has overcome the challenge of dealing with “go-betweens” when trying to contact physicians, such as having to navigate clinic answering systems or leaving a message with clinic nurses or receptionists [ 29 ], but certain barriers to communication still remain. Pharmacists still raised the concern that physicians would often not respond to their phone calls, a difficulty that has been highlighted in other studies as well [ 16 , 30 ]. Participants in our study reported that this difficulty in communication translated into longer waiting times for patients, who often became irritable and confrontational to pharmacy staff. This negatively impacted pharmacy staff morale and hindered their workflow. Furthermore, phone calls from pharmacists to physicians often disrupted physicians’ consultations. Pharmacists felt that this annoyed the physicians, resulting in some physicians being rude to the pharmacists. Naturally, this put a strain on the pharmacist-physician relationship and negatively affected team-based care. As one study in Canada reported, physicians and pharmacists both felt that nurturing a healthy pharmacist-physician relationship is important and that this relationship can further improve pharmacist-physician communication [ 16 ]. Another study in United States indicates that pharmacists’ understanding of physicians’ preferred mode of communication could enhance communication between them [ 31 ]. Thus, one can observe a negative cycle in our study, where the existing means for communication between pharmacists and physicians led to tension between both parties, which further strained the pharmacist-physician relationship. This study also highlighted that barriers emerged when physicians tried to communicate certain information to pharmacists.

Similar to a study conducted in the United States [ 29 ], our study surfaced that the main way physicians relayed information to pharmacists was via electronic medical records (EMR) instead of directly over the phone. This means of communication posed a challenge when physicians made inadequate and inappropriate documentation on the EMR. As pointed out by another study, pharmacists mentioned that their conversations with patients were frequently restricted due to inadequate details regarding patient medical conditions, reasons for prescribed medications, and physicians’ treatment strategies [ 30 ]. Should pharmacists need clarification regarding physicians’ documentation, they would have to call the physicians, leading to the many challenges raised above.

Finally, our study also pointed out that challenges faced in communication between physicians and patients posed barriers to pharmacists’ management of patients with hypertension. This was observed in two main ways. The first was that physicians sometimes did not elicit patients’ nonadherence to medications. The phenomenon where patients only reveal their difficulties with medication adherence to pharmacists and not physicians has been highlighted in other studies [ 30 , 32 ]. A systemic review conducted on communication between patients and healthcare professionals revealed that patients might choose not to disclose nonadherence to their physicians out of fear that the physician might react negatively [ 32 ]. When our study participants were asked why patients tend not to reveal their medication nonadherence to physicians, some posited that language barriers may have affected physician‒patient communication. This resulted in a “spill-over effect”, where lapses in communication translated into more work for the pharmacists who already faced time constraints. Some pharmacists in our study felt that this negatively impacted the care they could provide for their patients, while others viewed this as an important part of their role in the multidisciplinary team as a “safety net”.

Another barrier faced would be when physicians provide conflicting advice to patients compared to the advice pharmacists provide to patients. The pharmacists highlighted that the advice they provide was tailored to the patients’ context to best achieve medication adherence. However, many participants reported that patients tend to trust physicians more than pharmacists and would not even consider the advice given by pharmacists. In a review looking at challenges faced by pharmacists, some patients were unaware of pharmacists’ increasing role in healthcare and perceived pharmacists as merely dispensers of medicine rather than healthcare partners who collaborate with physicians [ 33 ]. This raises the issue of trust that patients place in different healthcare professionals. A study in the United Arab Emirates also pointed out that patients tend not to be receptive to the input of pharmacists when compared to that of physicians [ 34 ]. This limited the role a pharmacist can play in a multidisciplinary team and compromised patient care. More research should be conducted on the underlying beliefs and assumptions the public has of allied healthcare professionals, and interventions should be developed to counter any misconceptions to provide the best multidisciplinary care for all patients.

There are several limitations in this study. Firstly, the study was conducted in public primary care clinics in Singapore where there are in-house pharmacists; the findings may not be transferable to practices in the private sector which may not have an in-house pharmacist and has a smaller pool of doctors. Secondly, the interviews were conducted by a single researcher, who is a primary care physician. The clinical role of the interviewer may bring biases during the conduct of the study. However, the interviewer constantly reflected on his role and took steps to avoid leading questions during the interview. The data analysis was also conducted by researchers who were not involved in patient care.

This study highlights several barriers to communication that pharmacists face when managing patients with hypertension while working in a multidisciplinary team. Communication between pharmacists and patients can be challenging due to patient factors (language barrier and physical disabilities) and clinic factors (medication brand changes, use of video consultations). Barriers to communication between pharmacists and physicians include the existing means of pharmacist intervention (phone calls) being disruptive and ineffective and the prevalence of inadequate and inappropriate documentation on the EMR by physicians. Finally, barriers arising from physician‒patient communication also impact pharmacists, including when patients do not discuss medication nonadherence with physicians and when conflicting advice is given by physicians. These barriers may have a significant impact on patient safety and healthcare professional satisfaction. Thus, interventions involving pharmacists, physicians, and patients, need to be developed. This study has highlighted the need for interventions to help pharmacists support patients cope with medication brand changes. Also, to facilitate better communication between physicians and pharmacists, a more integrated platform that is less disruptive to the clinical workflow should be used. Finally, the electronic medical record system should include a decision support system to reduce physicians’ prescription and documentation errors; this will reduce the burden of pharmacists in rectifying the errors.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to participant and patient confidentiality.

Zhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet. 2021;398(10304):957–80.

Article   Google Scholar  

Singapore MoH. National Population Health Survey 2020 (Household Interview and Health Examination) 2020. Available from: https://www.moh.gov.sg/docs/librariesprovider5/default-document-library/nphs-2020-survey-report.pdf .

Khatib R, Schwalm J-D, Yusuf S, Haynes RB, McKee M, Khan M, et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLoS One. 2014;9(1):e84238.

Article   PubMed   PubMed Central   Google Scholar  

Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, et al. Trends in blood pressure control among US adults with hypertension, 1999–2000 to 2017–2018. JAMA. 2020;324(12):1190–200.

Article   PubMed   Google Scholar  

Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 2020;75(6):1334–57.

Article   CAS   PubMed   Google Scholar  

Wang G, Grosse SD, Schooley MW. Conducting research on the economics of hypertension to improve cardiovascular health. Am J Prev Med. 2017;53(6):S115–7.

Singapore MoH. Primary healthcare services 2022. Available from: https://www.moh.gov.sg/home/our-healthcare-system/healthcare-services-and-facilities/primary-healthcare-services#:~:text=including%20primary%20care).-,Polyclinics,preventive%20healthcare%20and%20health%20education .

Barry AR, Pammett RT. Applying the guidelines for pharmacists integrating into primary care teams. Can Pharm J. 2016;149(4):219–25.

Santschi V, Chiolero A, Colosimo AL, Platt RW, Taffé P, Burnier M, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3(2):e000718.

Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ. 2010;74(10):S7.

Bleakley A. The dislocation of medical dominance: making space for interprofessional care. J Interprof Care. 2013;27(sup2):24–30.

Bollen A, Harrison R, Aslani P, van Haastregt JC. Factors influencing interprofessional collaboration between community pharmacists and general practitioners—a systematic review. Health Soc Care Community. 2019;27(4):e189–212.

Nguyen J, Smith L, Hunter J, Harnett JE. Conventional and complementary medicine health care practitioners’ perspectives on interprofessional communication: a qualitative rapid review. Medicina. 2019;55(10):650.

Van C, Costa D, Abbott P, Mitchell B, Krass I. Community pharmacist attitudes towards collaboration with general practitioners: development and validation of a measure and a model. BMC Health Serv Res. 2012;12:1–10.

Löffler C, Koudmani C, Böhmer F, Paschka SD, Höck J, Drewelow E, et al. Perceptions of interprofessional collaboration of general practitioners and community pharmacists-a qualitative study. BMC Health Serv Res. 2017;17:1–7.

Mercer K, Neiterman E, Guirguis L, Burns C, Grindrod K. “My pharmacist”: creating and maintaining relationship between physicians and pharmacists in primary care settings. Res Social Adm Pharm. 2020;16(1):102–7.

Statistics SDo. Census of population 2020 statistical release 1 2020. Available from: https://www.singstat.gov.sg/-/media/files/publications/cop2020/sr1/findings.pdf .

Mays N, Pope C. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ. 1995;311(6996):42–5.

Huang C. Public healthcare system regrouped into three clusters 2021. Available from: https://www.healthxchange.sg/news/public-healthcare-system-regrouped-into-three-clusters .

Glaser B. Sensitivity: advances in the methodology of grounded theory. Mill Valley: Sociology Press; 1978.

Google Scholar  

Mills A, Durepos G, Wiebe E. Encyclopedia of case study research. Thousand Oaks: SAGE Publications, Inc.; 2010.

Proia KK, Thota AB, Njie GJ, Finnie RK, Hopkins DP, Mukhtar Q, et al. Team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med. 2014;47(1):86–99.

Khan T, Hassali M, Al-Haddad M. Patient-physician communication barrier: a pilot study evaluating patient experiences. J Young Pharm. 2011;3(3):250–5.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Al Shamsi H, Almutairi AG, Al Mashrafi S, Al KT. Implications of language barriers for healthcare: a systematic review. Oman Med J. 2020;35(2):e122.

Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225–35.

Parthab Taylor S, Nicolle C, Maguire M. Cross-cultural communication barriers in health care. Nurs Stand. 2013;27(31):35.

Suurmond J, Seeleman C. Shared decision-making in an intercultural context: barriers in the interaction between physicians and immigrant patients. Patient Educ Couns. 2006;60(2):253–9.

Olsson E, Kälvemark SS. Pharmacists’ experiences and attitudes regarding generic drugs and generic substitution: two sides of the coin. Int J Pharm Pract. 2012;20(6):377–83.

Curran GM, Freeman PR, Martin BC, Teeter BS, Drummond KL, Bradley K, et al. Communication between pharmacists and primary care physicians in the midst of a US opioid crisis. Res Social Adm Pharm. 2019;15(8):974–85.

Tarn DM, Paterniti DA, Wenger NS, Williams BR, Chewning BA. Older patient, physician and pharmacist perspectives about community pharmacists’ roles. Int J Pharm Pract. 2012;20(5):285–93.

Guthrie KD, Stoner SC, Hartwig DM, May JR, Nicolaus SE, Schramm AM, et al. Physicians’ preferences for communication of pharmacist-provided medication therapy management in community pharmacy. J Pharm Pract. 2017;30(1):17–24.

Stevenson FA, Cox K, Britten N, Dundar Y. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expect. 2004;7(3):235–45.

Ferreri SP, Hughes TD, Snyder ME. Medication therapy management: current challenges. Integr Pharm Res Pract. 2020;9:71–81.

PubMed   PubMed Central   Google Scholar  

Hasan S, Stewart K, Chapman C, Kong D. Physicians’ perspectives of pharmacist-physician collaboration in the United Arab Emirates: findings from an exploratory study. J Interprof Care. 2018;32(5):566–74.

Download references

Acknowledgements

We would like to acknowledge the following for their help: Prof Vikki Entwistle, Chair in Health Services Research and Philosophy at University of Aberdeen, for feedback on the manuscript; all clinics and participants who participated in the study.

This research was funded by SingHealth AM General Fund (14/FY2021/G2/01-A167), SingHealth Polyclinics, and Duke-NUS Medical School. The funding bodies had no influence on the design of the study, on the collection, analysis or interpretation of the data or on writing the manuscript.

Author information

Authors and affiliations.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

SingHealth Polyclinics, SingHealth, Singapore, Singapore

Ariffin Kawaja, Swee Phaik Ooi & Chirk Jenn Ng

Duke-NUS Medical School, Singapore, Singapore

Chirk Jenn Ng

You can also search for this author in PubMed   Google Scholar

Contributions

CJN conceived the study, conducted the interviews, analysed the data, and critically reviewed the manuscript. RT took field notes during the interviews, checked the transcripts, analysed the data, drafted and revised the manuscript. AK analysed the data and critically reviewed the manuscript. SPO interpreted the data and critically reviewed the manuscript. All authors approved the final manuscript.

Corresponding author

Correspondence to Chirk Jenn Ng .

Ethics declarations

Ethics approval and consent to participate.

This study received ethics approval from the SingHealth Centralised Institutional Review Board (CIRB Ref No: 2022/2168). All methods were carried out in accordance with relevant guidelines and regulations as set forth by the SingHealth Centralised Institutional Review Board. Written informed consent was obtained from all participants involved in the study.

Consent for publication

Not applicable as our study contains no identifiable information or images.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tan, R., Kawaja, A., Ooi, S.P. et al. Communication barriers faced by pharmacists when managing patients with hypertension in a primary care team: a qualitative study. BMC Prim. Care 25 , 100 (2024). https://doi.org/10.1186/s12875-024-02349-w

Download citation

Received : 18 September 2023

Accepted : 22 March 2024

Published : 27 March 2024

DOI : https://doi.org/10.1186/s12875-024-02349-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Hypertension
• Communication
• Pharmacists
• Multi-disciplinary team
• Primary care

BMC Primary Care

ISSN: 2731-4553

• General enquiries: [email protected]

Create Free Account or

• Acute Coronary Syndromes
• Anticoagulation Management
• Arrhythmias and Clinical EP
• Cardiac Surgery
• Cardio-Oncology
• Cardiovascular Care Team
• Congenital Heart Disease and Pediatric Cardiology
• COVID-19 Hub
• Diabetes and Cardiometabolic Disease
• Dyslipidemia
• Geriatric Cardiology
• Heart Failure and Cardiomyopathies
• Invasive Cardiovascular Angiography and Intervention
• Noninvasive Imaging
• Pericardial Disease
• Pulmonary Hypertension and Venous Thromboembolism
• Sports and Exercise Cardiology
• Stable Ischemic Heart Disease
• Valvular Heart Disease
• Vascular Medicine
• Clinical Updates & Discoveries
• Advocacy & Policy
• Perspectives & Analysis
• Meeting Coverage
• ACC Member Publications
• ACC Podcasts
• View All Cardiology Updates
• Earn Credit
• View the Education Catalog
• ACC Anywhere: The Cardiology Video Library
• CardioSource Plus for Institutions and Practices
• ECG Drill and Practice
• Heart Songs
• Nuclear Cardiology
• Online Courses
• Collaborative Maintenance Pathway (CMP)
• Understanding MOC
• Image and Slide Gallery
• Annual Scientific Session and Related Events
• Chapter Meetings
• Live Meetings
• Live Meetings - International
• Webinars - Live
• Webinars - OnDemand
• Certificates and Certifications
• ACC Accreditation Services
• ACC Quality Improvement for Institutions Program
• CardioSmart
• National Cardiovascular Data Registry (NCDR)
• Advocacy at the ACC
• Cardiology as a Career Path
• Cardiology Careers
• Cardiovascular Buyers Guide
• Clinical Solutions
• Clinician Well-Being Portal
• Diversity and Inclusion
• Infographics
• Innovation Program
• Mobile and Web Apps

Hypertension Blood Pressure Measurement Fact or Fiction – Case 2

A 64-year-old Asian man presents to the clinic for the first time for evaluation. Before entering the room, the clinician reviews the patient's vital signs, which are significant for a BP 151/92 mm Hg (similar to a previous reading of 149/91 mm Hg obtained at his primary care provider's office 1 month earlier).

After confirming with the nurse that the correct measurement techniques were used to obtain today's BP, the clinician recognizes that the patient may not be aware of the importance of his BP in reducing his risk of cardiovascular disease.

There are significant differences in BP awareness, control, and treatment rates based on race and ethnicity.

Show Answer

The correct answer is: Fact

Large differences exist in the awareness, treatment, and control rates of hypertension (HTN) across different racial and ethnic groups. In the American Heart Association (AHA) Heart Disease and Stroke Statistics-2020 Update, awareness, treatment, and control of HTN among Asian men were reported as being lower than among non-Hispanic White and non-Hispanic Black men but higher than among Hispanic men. 1 Similar findings were observed for Asian women. 1

Regarding this patient, only 50.3% of Asian men with HTN are aware of their diagnosis, with fewer receiving treatment (38.8%) or achieving BP control (13.6%). 2 After multivariable adjustment, compared with non-Hispanic White individuals, Asian American individuals are 25% less likely to be aware of their HTN, 19% less likely to have their HTN treated, and 32% less likely to achieve control of their HTN. 3

Whereas awareness levels are more evenly distributed across racial and ethnic groups, control rates for non-White individuals are lower than in their non-Hispanic White counterparts. Understanding the causes of these differences is critical to reduce disparities in care delivery and health care outcomes. Social determinants of health such as health literacy, socioeconomic status, and access to health care are major contributors to observed differences in BP control rates and awareness among racial and ethnic minority groups in the United States ( Figure 1 ). 4

Figure 1: Extent of Awareness, Treatment, and Control of High BP by Race/Ethnicity and Sex, United States (NHANES, 2013-2016)

This patient case quiz is part of the larger Overcoming Challenges in Hypertension Management grant. Educational grant support is provided by Medtronic. To visit the Overcoming Challenges in Hypertension Management grant page and access additional educational activities on this topic, click here .

• Virani SS, Alonso A, Benjamin EJ, et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation 2020;141:e139-e596.
• National Center for Health Statistics. NHANES Questionnaires, Datasets, and Related Documentation (Centers for Disease Control and Prevention website). Available at: https://wwwn.cdc.gov/nchs/nhanes/Default.aspx . Accessed 03/01/2024.
• Aggarwal R, Chiu N, Wadhera RK, et al. Racial/ethnic disparities in hypertension prevalence, awareness, treatment, and control in the United States, 2013 to 2018. Hypertension 2021;78:1719-26.
• Abrahamowicz AA, Ebinger J, Whelton SP, Commodore-Mensah Y, Yang E. Racial and ethnic disparities in hypertension: barriers and opportunities to improve blood pressure control. Curr Cardiol Rep 2023;25:17-27.

You must be logged in to save to your library.

Jacc journals on acc.org.

• JACC: Advances
• JACC: Basic to Translational Science
• JACC: CardioOncology
• JACC: Cardiovascular Imaging
• JACC: Cardiovascular Interventions
• JACC: Case Reports
• JACC: Clinical Electrophysiology
• JACC: Heart Failure
• Current Members
• Campaign for the Future
• Become a Member
• Renew Your Membership
• Member Benefits and Resources
• Member Sections
• ACC Member Directory
• ACC Innovation Program
• Our Strategic Direction
• Our History
• Our Bylaws and Code of Ethics
• Leadership and Governance
• Annual Report
• Industry Relations
• Support the ACC
• Jobs at the ACC
• Press Releases
• Social Media
• Book Our Conference Center

Clinical Topics

• Chronic Angina
• Congenital Heart Disease and     Pediatric Cardiology
• Diabetes and Cardiometabolic     Disease
• Hypertriglyceridemia
• Invasive Cardiovascular Angiography    and Intervention
• Pulmonary Hypertension and Venous     Thromboembolism

Latest in Cardiology

Education and meetings.

• Online Learning Catalog
• Products and Resources
• Annual Scientific Session

Tools and Practice Support

• Quality Improvement for Institutions
• Accreditation Services
• Practice Solutions

Heart House

• 2400 N St. NW
• Washington , DC 20037
• Email: [email protected]
• Phone: 1-202-375-6000
• Toll Free: 1-800-253-4636
• Fax: 1-202-375-6842
• Media Center
• ACC.org Quick Start Guide
• Advertising & Sponsorship Policy
• Clinical Content Disclaimer
• Editorial Board
• Privacy Policy
• Registered User Agreement
• Terms of Service
• Cookie Policy

© 2024 American College of Cardiology Foundation. All rights reserved.

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Case study: 60-year-old female presenting with shortness of breath.

Deepa Rawat ; Sandeep Sharma .

Affiliations

Last Update: February 20, 2023 .

• Case Presentation

The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath.  Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep.

She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea.

She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that are new-onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath.

There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.

Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity.  Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.

Her current medications include fluticasone-vilanterol 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, albuterol-ipratropium inhaled every 4 hours PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily.

Physical Exam

Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, HT 160 cm, WT 100 kg, BMI 39.1, and O2 saturation 90% on room air.

Constitutional:  Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets.

HEENT: 

• Head: Normocephalic and atraumatic
• Mouth: Moist mucous membranes 
• Macroglossia
• Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present.
• Neck: Neck supple. No JVD present. No masses or surgical scarring. 
• Throat: Patent and moist

Cardiovascular:  Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities.

Pulmonary/Chest:  No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. The patient was barely able to finish a full sentence due to shortness of breath.

Abdominal:  Soft. Obese. Bowel sounds are normal. No distension and no tenderness

Skin: Skin is very dry

Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses

• Initial Evaluation

Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate the presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.

Largely unremarkable and non-contributory to establish a diagnosis.

Showed creatinine elevation above baseline from 1.08 base to 1.81, indicating possible acute injury. EGFR at 28 is consistent with chronic renal disease. Calcium was elevated to 10.2. However, when corrected for albumin, this corrected to 9.8 mg/dL. Mild transaminitis is present as seen in alkaline phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload.

Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air, indicating respiratory alkalosis with hypoxic respiratory features.

Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of her known chronic renal failure and acute injury indicated by the above creatinine value, a differential of rhabdomyolysis is determined.

Influenza A and B: Negative

Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF.

Chest X-ray

Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings were noted. Small bilateral pleural effusions

Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right

• Differential Diagnosis
• Acute on chronic COPD exacerbation
• Acute on chronic renal failure
• Bacterial pneumonia
• Congestive heart failure
• Pericardial effusion
• Hypothyroidism
• Influenza pneumonia
• Pulmonary edema
• Pulmonary embolism
• Confirmatory Evaluation

On the second day of the admission patient’s shortness of breath was not improved, and she was more confused with difficulty arousing on conversation and examination. To further elucidate the etiology of her shortness of breath and confusion, the patient's husband provided further history. He revealed that she is poorly compliant with taking her medications. He reports that she “doesn’t see the need to take so many pills.”

Testing was performed to include TSH, free T4, BNP, repeated arterial blood gas, CT scan of the chest, and echocardiogram. TSH and free T4 evaluate hypothyroidism. BNP evaluates fluid load status and possible congestive heart failure. CT scan of the chest will look for anatomical abnormalities. An echocardiogram is used to evaluate left ventricular ejection fraction, right ventricular function, pulmonary artery pressure, valvular function, pericardial effusion, and any hypokinetic area.

• TSH: 112.717 (H)
• Free T4: 0.56 (L)
• TSH and Free T4 values indicate severe primary hypothyroidism. 

BNP can be falsely low in obese patients due to the increased surface area. Additionally, adipose tissue has BNP receptors which augment the true BNP value. Also, African American patients with more excretion may have falsely low values secondary to greater excretion of BNP. This test is not that helpful in renal failure due to the chronic nature of fluid overload. This allows for desensitization of the cardiac tissues with a subsequent decrease in BNP release.

Repeat arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4, HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen.

CT chest without contrast was primarily obtained to evaluate the left hemithorax, especially the retrocardiac area.

Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. Some left lung base atelectasis with minimal airspace disease.

Echocardiogram

The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated.

The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. A dedicated tamponade study was not performed. 

The estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated.

The aortic valve is abnormal in structure and exhibits sclerosis.

The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present.

• Myxedema coma or severe hypothyroidism
• Pericardial effusion secondary to myxedema coma
• COPD exacerbation
• Acute on chronic hypoxic respiratory failure
• Acute respiratory alkalosis
• Bilateral community-acquired pneumonia
• Small bilateral pleural effusions
• Acute mild rhabdomyolysis
• Acute chronic, stage IV, renal failure
• Elevated troponin I levels, likely secondary to Renal failure 
• Diabetes mellitus type 2, non-insulin-dependent
• Extreme obesity
• Hepatic dysfunction

The patient was extremely ill and rapidly decompensating with multisystem organ failure, including respiratory failure, altered mental status, acute on chronic renal failure, and cardiac dysfunction. The primary concerns for the stability of the patient revolved around respiratory failure coupled with altered mental status. In the intensive care unit (ICU), she rapidly began to fail BiPAP therapy. Subsequently, the patient was emergently intubated in the ICU.  A systemic review of therapies and hospital course is as follows:

Considering the primary diagnosis of myxedema coma, early supplementation with thyroid hormone is essential. Healthcare providers followed the American Thyroid Association recommendations, which recommend giving combined T3 and T4 supplementation; however, T4 alone may also be used. T3 therapy is given as a bolus of 5 to 20 micrograms intravenously and continued at 2.5 to 10 micrograms every 8 hours. An intravenous loading dose of 300 to 600 micrograms of T4 is followed by a daily intravenous dose of 50 to 100 micrograms. Repeated monitoring of TSH and T4 should be performed every 1 to 2 days to evaluate the effect and to titrate the dose of medication. The goal is to improve mental function. Until coexistent adrenal insufficiency is ruled out using a random serum cortisol measurement, 50 to 100 mg every 8 hours of hydrocortisone should be administered. In this case, clinicians used hydrocortisone 100 mg IV every 8 hours. Dexamethasone 2 to 4 mg every 12 hours is an alternative therapy.

The patient’s mental status rapidly worsened despite therapy. In the setting of her hypothyroidism history, this may be myxedema coma or due to the involvement of another organ system. The thyroid supplementation medications and hydrocortisone were continued. A CT head without contrast was normal.

Respiratory

For worsening metabolic acidosis and airway protection, the patient was emergently intubated. Her airway was deemed high risk due to having a large tongue, short neck, and extreme obesity. As the patient’s heart was preload dependent secondary to pericardial effusion, a 1-liter normal saline bolus was started. Norepinephrine was started at a low dose for vasopressor support, and ketamine with low dose Propofol was used for sedation. Ketamine is a sympathomimetic medication and usually does not cause hypotension as all other sedatives do. The patient was ventilated with AC mode of ventilation, tidal volume of 6 ml/kg ideal body weight, flow 70, initial fio2 100 %, rate 26 per minute (to compensate for metabolic acidosis), PEEP of 8.

Cardiovascular

She was determined to be hemodynamically stable with a pericardial effusion. This patient’s cardiac dysfunction was diastolic in nature, as suggested by an ejection fraction of 66% to 70%. The finding of posterior pericardial effusion further supported this conclusion. The posterior nature of this effusion was not amenable to pericardiocentesis. As such, this patient was preload dependent and showed signs of hypotension. The need for crystalloid fluid resuscitation was balanced against the impact increased intravascular volume would have on congestive heart failure and fluid overload status. Thyroid hormone replacement as above should improve hypotension. However, vasopressor agents may be used to maintain vital organ perfusion targeting a mean arterial pressure of greater than 65 mm Hg as needed. BP improved after fluid bolus, and eventually, the norepinephrine was stopped. Serial echocardiograms were obtained to ensure that the patient did not develop tamponade physiology. Total CK was elevated, which was likely due to Hypothyroidism compounded with chronic renal disease.

Infectious Disease

Blood cultures, urine analysis, and sputum cultures were obtained. The patient's white blood cell count was normal. This is likely secondary to her being immunocompromised due to hypothyroidism and diabetes. In part, the pulmonary findings of diffuse edema and bilateral pleural effusions can be explained by cardiac dysfunction. Thoracentesis of pleural fluid was attempted, and the fluid was analyzed for cytology and gram staining to rule out infectious or malignant causes as both a therapeutic and diagnostic measure. Until these results return, broad-spectrum antibiotics are indicated and may be discontinued once the infection is ruled out completely.

Gastrointestinal

Nasogastric tube feedings were started on the patient after intubation. She tolerated feedings well. AST and ALT were mildly elevated, which was thought to be due to hypothyroidism, and as the TSH and free T4 improved, her AST and ALT improved. Eventually, these values became normal once her TSH level was close to 50.

Her baseline creatinine was found to be close to 1.08 in prior medical records. She presented with a creatinine of 1.8 in the emergency department. Since hypothyroidism causes fluid retention in part because thyroid hormone encourages excretion of free water and partly due to decreased lymphatic function in returning fluid to vascular circulation.  Aggressive diuresis was attempted. As a result, her creatinine increased initially but improved on repeated evaluation, and the patient had a new baseline creatinine of 1.6. Overall she had a net change in the fluid status of 10 liters negative by her ten days of admission in the ICU.

Mildly anemic otherwise, WBC and platelet counts were normal. Electrolyte balance should be monitored closely, paying attention to sodium, potassium, chloride, and calcium specifically as these are worsened in both renal failure and myxedema. 

Daily sedation vacations were enacted, and the patient's mental status improved and was much better when TSH was around 20. The bilateral pleural effusions improved with aggressive diuresis. Breathing trials were initiated when the patient's fio2 requirements decreased to 60% and a PEEP of 8. She was eventually extubated onto BiPAP and then high-flow nasal cannula while off of BiPAP. Pericardial fluid remained stable, and no cardiac tamponade pathology developed. As a result, it was determined that a pericardial window was unnecessary. Furthermore, she was not a candidate for pericardiocentesis as the pericardial effusion was located posterior to the heart. Her renal failure improved with improved cardiac function, diuretics, and thyroid hormone replacement.

After extubation patient had speech and swallow evaluations and was able to resume an oral diet. The patient was eventually transferred out of the ICU to the general medical floor and eventually to a rehabilitation unit.

Despite the name myxedema coma, most patients will not present in a coma status. This illness is at its core a severe hypothyroidism crisis that leads to systemic multiorgan failure. Thyroid hormones T3, and to a lesser extent, T4 act directly on a cellular level to upregulate all metabolic processes in the body. Therefore, deficiency of this hormone is characterized by systemic decreased metabolism and decreased glucose utilization along with increased production and storage of osmotically active mucopolysaccharide protein complexes into peripheral tissues resulting in diffuse edema and swelling of tissue. [1]

Myxedema coma is an illness that occurs primarily in females at a rate of 4:1 compared to men. It typically impacts the elderly at the age of greater than 60 years old, and approximately 90% of cases occur during the winter months. Myxedema coma is the product of longstanding unidentified or undertreated hypothyroidism of any etiology. Thyroid hormone is necessary throughout the body and acts as a regulatory hormone that affects many organ systems. [2] In cardiac tissues, myxedema coma manifests as decreased contractility with subsequent reduction in stroke volume and overall cardiac output.  Bradycardia and hypotension are typically present also. Pericardial effusions occur due to the accumulation of mucopolysaccharides in the pericardial sac, which leads to worsened cardiac function and congestive heart failure from diastolic dysfunction. Capillary permeability is also increased throughout the body leading to worsened edema. Electrocardiogram findings may include bradycardia and low-voltage, non-specific ST waveform changes with possible inverted T waves.

Neurologic tissues are impacted in myxedema coma leading to the pathognomonic altered mental status resulting from hypoxia and decreased cerebral blood flow secondary to cardiac dysfunction as above. Additionally, hypothyroidism leads to decreased glucose uptake and utilization in neurological tissue, thus worsening cognitive function.

The pulmonary system typically manifests this disease process through hypoventilation secondary to the central nervous system (CNS) depression of the respiratory drive with blunting of the response to hypoxia and hypercapnia. Additionally, metabolic dysfunction in the muscles of respiration leads to respiratory fatigue and failure, macroglossia from mucopolysaccharide driven edema of the tongue leads to mechanical obstruction of the airway, and obesity hypoventilation syndrome with the decreased respiratory drive as most hypothyroid patients suffer from obesity.

Renal manifestations include decreased glomerular filtration rate from the reduced cardiac output and increased systemic vascular resistance coupled with acute rhabdomyolysis lead to acute kidney injury. In the case of our patient above who has a pre-existing renal disease status post-nephrectomy, this is further worsened.  The net effect is worsened fluid overload status compounding the cardiac dysfunction and edema. [3]

The gastrointestinal tract is marked by mucopolysaccharide-driven edema as well leading to malabsorption of nutrients, gastric ileus, and decreased peristalsis. Ascites is common because of increased capillary permeability in the intestines coupled with coexistent congestive heart failure and congestive hepatic failure. Coagulopathies are common to occur as a result of this hepatic dysfunction.

Evaluation: The diagnosis of myxedema coma, as with all other diseases, is heavily reliant on the history and physical exam. A past medical history including hypothyroidism is highly significant whenever decreased mental status or coma is identified. In the absence of identified hypothyroidism, myxedema coma is a diagnosis of exclusion when all other sources of coma have been ruled out. If myxedema coma is suspected, evaluation of thyroid-stimulating hormone (TSH), free thyroxine (T4), and serum cortisol is warranted. T4 will be extremely low. TSH is variable depending on the etiology of hypothyroidism, with a high TSH indicating primary hypothyroidism and a low or normal TSH indicating secondary etiologies. Cortisol may be low indicating adrenal insufficiency because of hypothyroidism.  [4]

Prognosis: Myxedema coma is a medical emergency. With proper and rapid diagnosis and initiation of therapy, the mortality rate is still as high as 25% to 50%. The most common cause of death is due to respiratory failure. The factors which suggest a poorer prognosis include increased age, persistent hypothermia, bradycardia, low score Glasgow Coma Scale, or multi-organ impairment indicated by high APACHE (Acute Physiology and Chronic Health Evaluation) II score. For these reasons, placement in an intensive care unit with a low threshold for intubation and mechanical ventilation can improve mortality outcomes. [3] [5]

• Pearls of Wisdom
• Not every case of shortness of breath is COPD or congestive heart failure (CHF). While less likely, a history of hypothyroidism should raise suspicion of myxedema coma in a patient with any cognitive changes.
• Myxedema is the great imitator illness that impacts all organ systems. It can easily be mistaken for congestive heart failure, COPD exacerbation, pneumonia, renal injury or failure, or neurological insult.
• Initial steps in therapy include aggressive airway management, thyroid hormone replacement, glucocorticoid therapy, and supportive measures.
• These patients should be monitored in an intensive care environment with continuous telemetry. [6]
• Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis, particularly in more challenging cases such as this one. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Case Study of 60 year old female presenting with Shortness of Breath Contributed by Sandeep Sharma, MD

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Rawat D, Sharma S. Case Study: 60-Year-Old Female Presenting With Shortness of Breath. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

• Bulk download StatPearls data from FTP

Related information

• PubMed Links to PubMed

Similar articles in PubMed

• Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [StatPearls. 2024] Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. Sharma S, Hashmi MF, Rawat D. StatPearls. 2024 Jan
• Acute Exacerbation of COPD. [J Educ Teach Emerg Med. 2023] Acute Exacerbation of COPD. Pappas D, Vempati A. J Educ Teach Emerg Med. 2023 Apr; 8(2):S35-S61. Epub 2023 Apr 30.
• Review Breathlessness with pulmonary metastases: a multimodal approach. [J Adv Pract Oncol. 2013] Review Breathlessness with pulmonary metastases: a multimodal approach. Brant JM. J Adv Pract Oncol. 2013 Nov; 4(6):415-22.
• Stress Cardiomyopathy in the Setting of COPD Exacerbation. [J Investig Med High Impact Cas...] Stress Cardiomyopathy in the Setting of COPD Exacerbation. Landefeld K, Saleh Q, Sander GE. J Investig Med High Impact Case Rep. 2015 Oct-Dec; 3(4):2324709615612847. Epub 2015 Oct 14.
• Review Palliative Chemotherapy: Does It Only Provide False Hope? The Role of Palliative Care in a Young Patient With Newly Diagnosed Metastatic Adenocarcinoma. [J Adv Pract Oncol. 2017] Review Palliative Chemotherapy: Does It Only Provide False Hope? The Role of Palliative Care in a Young Patient With Newly Diagnosed Metastatic Adenocarcinoma. Doverspike L, Kurtz S, Selvaggi K. J Adv Pract Oncol. 2017 May-Jun; 8(4):382-386. Epub 2017 May 1.

Recent Activity

• Case Study: 60-Year-Old Female Presenting With Shortness of Breath - StatPearls Case Study: 60-Year-Old Female Presenting With Shortness of Breath - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers