Barriers to emergency physician diagnosis and treatment of uncontrolled chronic hypertension

Despite recent expansions in health insurance coverage following the implementation of the Affordable Care Act, patients from marginalized groups still face numerous barriers in accessing primary care and often rely on emergency departments (EDs) as their main source of health care [1,2]. EDs are not the ideal setting in which to provide primary care; however, in medically underserved communities, they can play important roles in screening and referring patients with previously undiagnosed medical conditions [3]. Within this context, the American College of Emergency Physicians has published clinical policies regarding the appropriate management of asymptomatic hypertension (HTN) [4,5].

Unfortunately, implementation of these and other evidence-based measures to achieve better long-term blood pressure (BP) control for hypertensive ED patients has been inconsistent [6,7]. A previous study identified knowledge deficits, time constraints, and uncertainty regarding ED BP readings as prevalent physician barriers to better ED treatment of asymptomatic HTN [8]. In this study, we surveyed a national sample of emergency physicians on their perceived barriers in establishing an ED diagnosis of HTN and ED treatment of such patients.

An online survey was sent to all members of the Emergency Medicine Practice Research Network, a nationally representative sample of board-certified emergency physicians. The composition of the Emergency Medicine Practice Research Network participants closely mirrors the national American College of Emergency Physicians membership in terms of sex, age, years in practice, geographic region, and characteristics. Descriptive statistics were used to quantify the responses. The narrative responses were analyzed for recurrent themes and categorized into discrete domains using a grounded theory methodology.

One thousand two hundred surveys were distributed by e-mail in with a response rate of 17% (n = 199). Respondents’ demographic and practice characteristics are described in Table 1 and compared with a national emergency physician workforce assessment [9] and an inventory of EDs by population [10]. The most common barriers to diagnosis of HTN were uncertainty regarding the validity of ED BP measurements (92%), reluctance to diagnose a condition which cannot be comprehensively managed in the ED setting (29%), concern over secondary loss to the patient such as increased insurance premiums (14%), and concern that this practice may lead to increased use of EDs for primary care (14%). Regarding treatment of HTN, physicians identified diagnostic uncertainty (82%), discomfort with prescribing long-term medications without established follow-up (39%), and liability for medication adverse effects (28%). (See Table 2.)

Table 1.

Demographic and practice characteristics of respondents

Variable	Asymptomatic HTN Survey	National Study of the Emergency Physician Workforce, 2008	2013 National Emergency Department Inventory
Sex (% male)	77%	75%	NA
Years in practice	<5:10% 5–10: 23% 11–20: 32% >21: 35%	<5:25% 5–9: 22% 10–19:28% >20: 24%
Volume of primary practice setting in visits/y	<20 000: 9% 20 000–50 000: 31% >50 000: 60%	NA	<20 000: 48% 20 000–50 000:34% >50 000: 16%

Cumulative proportions do not always equal 100%, as rounding was used. Data sources: National Study of the Emergency Physician Workforce, Ann Emerg Med. 2009;54(3):349–359; Emergency Medicine Network, 2013 National Emergency Department Inventory—USA, http://www.emnet-usa.org/nedi/NEDI2013statedata.xls. Accessed 10/30/2015.

Table 2.

Prevalence of various self-reported barriers to ED diagnosis and treatment of hypertension

Barriers to ED diagnosis of HTN		Barriers to prescription ofantihypertensives
92%	ED BP readings are often falsely elevated because of pain and anxiety.	82%	ED BP readings are often falsely elevated because of pain and anxiety.
29%	This diagnosis should only be made by the clinician who will then assume responsibility for long-term treatment.	39%	This prescription should only be given by the clinician who assumes responsibility for the long-term treatment.
25%	Other (fill in below)	28%	I am concerned about taking on liability for adverse effects such as angioedema and hypotension.
14%	I don’t want to burden the patient with a diagnosis which may lead to secondary loss (ie, increase in insurance rates).	19%	Other (fill in below)
14%	This will encourage inappropriate use of the ED for primary care.	17%	This will encourage inappropriate use of the ED for primary care.
5%	I am not familiar with the diagnostic criteria for hypertension.	14%	I am not familiar with the medication classes and dosing.

^*Proportions do not equal 100%, as respondents were able to choose more than one answer.

Analysis of free-text comments revealed several recurring themes, which can be interpreted as belonging to one of several domains. Disease-centered topics were the most frequently noted. These were focused on the unreliability of an ED diagnosis and the perception that chronic diseases can only be managed with long-term follow-up. Physician-centered concerns were legal liability for poor outcomes and adverse medication effects, lack of comfort and knowledge with chronic disease management, and a sense that EDs should not treat problems that are not “true emergencies.” System-centered issues were resource constraints, such as time, lack of staff expertise in patient education, as well as potential delays to disposition by ordering associated laboratory testing. Patient-centered perceived barriers were concern of adverse effects of medications and unreliability in medication adherence and proper follow-up.

Despite the global burden of disease and potential morbidity and mortality, uncontrolled HTN is often not adequately addressed in the ED setting. Previous studies describe resource constraints, knowledge deficits, and uncertainty regarding the validity of ED BP measurements in the diagnosis of HTN [8] as major barriers. Newly cited barriers in our study include liability concerns, an unwillingness to provide treatment for a chronic disease, and fear that this practice may increase what is perceived as inappropriate use of the ED for primary care. An interesting and paradoxical finding is that many respondents reported perceived poor access to primary care follow-up as reason to withhold ED management, yet from a public health perspective, these patients are most in need of ED-based HTN management.

Strategies to address physician barriers, based on findings from this and similar studies, are crucial if EDs are to have an impact on long-term outcomes in an integrated health care model. The validity of ED BP measurements has long been questioned, but several studies suggest that these readings correlate well with ambulatory or office BP measurements [11,12]. Improved coordination between ED physicians and destination primary care clinics, as well as improved access for underserved communities, may enable ED physicians to initiate treatment more readily.

Several recent publications have demonstrated the safety and efficacy of providing prescriptions for a variety of medications in EDs [13–15]. To decrease the potentially costly downstream effects of HTN including heart failure, stroke, and myocardial infarction, a population-targeted strategy that includes the ED is vital. Understanding physician barriers is a crucial step in designing related policies and sustainable physician-facing protocols for interventions. Our proposed taxonomy of these barriers into disease, patient, physician, and system domains will inform future research efforts in this field.