Barriers of Implementing Guideline Recommendations of Cardiovascular Risk Management of Hypertension Among Dutch Health Professionals

Background: Hypertension presents a public health challenge globally, both in developing and developed countries such as the Netherlands. Complications of hypertension accounted for a total number of 10.46 million deaths every year in the world, and disability-adjusted life years associated with high blood pressure is 143.0 million in 2015. Among Dutch people aged between 30 and 70, 31.4% suffer from hypertension. Dutch guideline recommendations for treating patients with SBP between 160 and 180 mmHg is unique: low-risk patients are recommended without BP lowering medication, and middle-risk patients should be treated only in the presence of other risk-increasing factors. For these two groups of patients, guidelines from other countries, like United Kingdom and the United States, suggests “lifestyle advice with prompt drug initiation”. This study explores attitudes of health professionals, the target users of the unique Dutch guideline, towards the risk table and two guideline recommendations of commencing antihypertensive drug treatment for low- and middle-risk patients. In addition to health professionals’ attitude, this study also explores their perceived application barriers of the risk table. The risk table and two recommendations are only a small part of the CVRM guideline. This study focused on the risk table and the two recommendations because these are the guidance for treating hypertension patients.

Methods: A cross-sectional, mixed-method study was conducted in the Netherlands, mainly in Amsterdam. A total of 77 online questionnaires in English were conducted among health professionals in the Netherlands, while 13 face-to-face in-depth interviews in English were conducted among participants in Amsterdam. All participants completed the online questionnaire that assessed their knowledge, attitude, and practice of the Dutch General Practitioner’s Society (Nederlands Huisartsen Genootschap NHG) CVRM guideline and the risk table, as well as their attitude towards the two recommendations of antihypertensive drug prescription for low- and middle-risk patients. The in-depth interview aimed to further explore barriers of applying the risk table and the reasons for their attitude towards the two recommendations.

Results: Majority of our survey respondents have positive attitudes towards the NHG CVRM guideline in general and the risk table. Knowledge and attitude are not barriers of applying NHG CVRM guideline. All the respondents reported that they knew the existence of the guideline, and almost all of them (97%) agreed that they knew the guideline content. 92% respondents think that NHG CVRM guidelines are valuable, and 92% report that they believe NHG guidelines are well-supported by scientific evidence. Despite that only 3.9% participants reported they did not apply the risk table to every patient, health professionals perceived lacking important risk factors as an important barrier of applying the risk table.

Regarding attitudes towards pharmacological treatment for low- and middle-risk patents, 66% agreed that middle-risk patients required drug treatment only in the event of risk-increasing factors and SBP > 140mmHg and/or LDL> 2.5 mmol/L, 58% agreed low-risk patients rarely required drug treatment. The most reported reasons to follow the unique recommendations include: follow the guideline, clinical uncertainty of the persistency of the elevated BP, perceived patient attitude and drug adherence, and drug burden. Confusion of guideline interpretation for treatment advice on low-risk patient with SBP over 180 mmHg is detected in this study.

A significant relationship existed between attitudes towards lowering current treatment threshold and sex (p=.011). Female health professionals were more likely to agree with lowering treatment threshold compared to male.

Conclusions: Knowledge is not a barrier of applying NHG CVRM guideline, and attitudes towards the guideline are found to be generally positive. The highest perceived barriers to applying the risk table is lack of important risk factors, for example SES, ethnicity, psychological factors, physical exercise, BMI, family history of CVD, and chronic conditions like chronic kidney diseases and autoimmune disease. Most participants agree that low-risk patients rarely require drug treatment, and middle-risk patients require drug treatment only in the event of risk-increasing factors and SBP> 140mmHg and/or LDL> 2.5 mmol/L. The most reported reasons to follow the unique recommendations include: follow the guideline, clinical uncertainty of the persistency of the elevated BP, perceived patient attitude and drug adherence, and drug burden. Confusion of guideline interpretation for treatment advice on low-risk patient with SBP over 180 mmHg is detected in this study.