Organizational Determinants to Hypertension Management: Adapting a Health Equity Framework to Examine Processes at Two Academic Health Systems

Background: Hypertension management is a national priority. However, hypertension control rates are suboptimal and vary across clinics, even among those in the same health system and geographic region.

Objective: To identify organizational barriers and facilitators that impact hypertension management at the provider, clinic, and health system level.

Design: Semi-structured interviews were conducted to assess patient and provider experiences with hypertension care.

Participants: Twenty-five providers and 22 patients with uncontrolled hypertension were recruited from thirteen high- and low-performing primary care clinics across two health systems in North Carolina and Kansas.

Approach: Interviews were analyzed using both inductive and deductive coding methodologies. A health equity framework scaffolded interview guide design and codebook development, with thematic analysis employed to categorize emergent themes.

Key results: Participants discussed organizational and clinic-level barriers and facilitators that impact hypertension management, with health systems' resource centralization being frequently mentioned. Some participants lauded centralized interventions for improving patient access and increasing touchpoints, while others lamented reductions in clinic staffing to accommodate centralized workflows. Insufficient in-clinic staffing and blood pressure (BP) measurement equipment, limited exam rooms, short appointment duration, and hurried clinic environments were all mentioned as challenges to hypertension management, particularly as they hindered adherence to BP recheck policies. Appointment availability was mentioned as a barrier; however, some providers referenced clinics' use of virtual and/or nurse-specific visits as a mechanism to increase patient access. Multiple providers noted that tasks central to hypertension management, like BP telemonitoring and MyChart correspondence, go unaccounted for on their schedules and can lead to unpaid work, which they linked with increased stress and burnout.

Conclusions: Primary care clinics experience multiple interrelated organizational barriers to effective hypertension management. Future studies should examine the impact of different clinic staffing models, including multidisciplinary care teams, telemedicine, and remote BP monitoring, on BP outcomes in diverse primary care settings.