Implementation of Hypertension Clinical Practice Guidelines: A Systematic Review of Strategies to Change Physician Behavior and Improve Patient Outcomes
Background: Hypertension remains a major cause of cardiovascular disease morbidity and mortality worldwide. There is strong evidence that blood pressure control is associated with significant reduction in morbidity and mortality caused by cardiovascular events. However, only one-third of Americans with hypertension have adequate blood pressure control. Clinical practice guidelines have been established to guide physician treatment of hypertension, yet many physicians do not follow these guidelines. In response to this problem, there is a growing body of literature regarding interventions designed to help physicians adhere to hypertension clinical practice guidelines. Objectives: To systematically identify, appraise and synthesize studies of professional educational or quality assurance interventions designed to improve physician adherence to hypertension clinical practice guidelines. The effectiveness of various intervention strategies in changing physician behavior and improving patient outcomes will be evaluated. Research design: I performed a systematic review of studies published in MEDLINE between 1966 and 2005 describing interventions to improve physician adherence to hypertension guidelines in primary care. Randomized controlled trials, cohort studies, case control studies and time-series analyses describing physician targeted educational or quality assurance interventions with objective measures of physician hypertension management behavior or patient blood pressure outcomes were included. Data from each study was abstracted in to evidence tables for review and all studies were assigned a quality grade based (good, fair, poor) based on their study design and potential for selection bias, measurement bias, and confounding. Results: The initial Medline search yielded 574 citations of which 32 were included in this review. Three citations additional were identified through manual searching, These studies examined the following interventions: educational outreach (n=12), local opinion leaders (n=5), audit and feedback (n=16), decision support (n=5), reminders (n=11), and local consensus development (n=4). Interventions involving Educational Outreach, especially when combined with Local Opinion Leader and Audit and Feedback, resulted in moderate changes in prescribing behavior and small increases in blood pressure control. No studies examined the independent effects of educational outreach or local opinion leaders, but audit and feedback appeared to have no effect on its own. Interventions involving Reminders were highly effective in increasing screening and prescribing, but did not reduce blood pressure; while decision support was generally ineffective on its own. Local Consensus Development of Guidelines had moderate to large effects on prescribing behavior and had mixed results on blood pressure control. Conclusions: No single educational or quality assurance intervention is superior to others in improving physician adherence to hypertension guidelines, although several interventions appear to be ineffective or untested on their own. Multifaceted Interventions especially those involving Educational Outreach by Local Opinion Leaders, Audit and Feedback, Local Consensus Guideline Development and/or Reminders appear to be the most promising physician oriented interventions to improve patient blood pressure control.Master of Public Healt
