Undiagnosed hypertension (HTN) is frequently encountered in the emergency department (ED). Ethnic minorities and those of lower socio-economic standing are disproportionately affected by HTN and are also less likely to receive adequate blood pressure (BP) control. Although many factors may contribute to this, the failure to recognize and refer patients with elevated BP constitutes a major public health concern. Given the significant morbidity and mortality of undiagnosed HTN, it is crucial to understand health care provider barriers that may contribute to lack of reassessment of an elevated BP and referral in patients with previously undiagnosed HTN. Addressing the existing literature gap and identifying these barriers will ultimately guide future research and active interventions that may be most effective for prompting health care providers to recommend out-patient follow-up. Although documentation of the extent of non-referral has been provided, factors that may contribute to lack of referral in patients with previously undiagnosed HTN in a variety of ED providers (registered nurse [RN], nurse practitioner [NP], physician [MD], and physician's assistant [PA]) have not been explored, nor have the two approaches been used together to fully illuminate the problem. Therefore, the specific aims of the proposed study are to: 1) Examine the ED provider barriers - knowledge of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7) and American College of Emergency Physicians (ACEP) recommendations, attitudes toward these recommendations and external factors (patient, guideline and environmental factors [time, resources, and organizational constraints]) - that are associated with ED provider practice patterns (reassessment and/or referral of patients with elevated BP);and 2) Determine the prevalence of elevated BP according to JNC-7 categories (pre-HTN [120-139/80-89 mm Hg];stage 1 HTN [140-159/90-99 mm Hg];stage 2 HTN e160/e100 mm Hg]), and the factors associated with ED provider practice patterns (reassessment and/or referral of patients with elevated BP). The proposed study will be designed in 2 parts. First, to address Aim 1, a cross-sectional web-based survey designed to examine barriers that inhibit ED providers from re-assessing and/or referring patients with elevated BP for further evaluation, management, and/or treatment will be conducted. A retrospective chart review will be completed to examine the prevalence of elevated BP and factors associated with associated with ED provider practice patterns (reassessment and/or referral of patients with elevated BP) in Aim 2. The study will be conducted in the New York City Health and Hospitals Corporation (HHC), which is the largest municipal hospital and health care system in the country. The research study and the proposed research training plan will prepare the applicant, who is a ethnic minority nurse and family nurse practitioner, for a career as a nursing scientist dedicated to the study of health disparities.
Emergency Department providers may have potential to reduce the long-term consequences of undiagnosed high blood pressure. Examining barriers in the form of knowledge, attitudes, and external factors that may influence these providers to reassess an elevated blood pressure during the visit and refer patients with previously undiagnosed HTN is crucial for this to occur. Identifying these barriers will ultimately guide future research and contribute to efforts to reduce health disparities.
|Souffront, Kimberly; Chyun, Deborah; Kovner, Christine (2015) Barriers to referral for elevated blood pressure in the emergency department and differences between provider type. J Clin Hypertens (Greenwich) 17:207-14|