Treating hypertension and hyperlipidemia in an emerging Accountable Care Organization: physicians’ perspectives on health information technology, financial incentives and the patient-doctor relationship

Main Article Content

Roberta E Goldman
Steven R. Simon


Rationale, aims, and objective: Accountable care organizations (ACOs) in the United States will employ health information technology, multidisciplinary care teams and financial incentives to achieve treatment goals for chronic conditions, such as hypertension and hyperlipidemia.  Whether these approaches will enable physicians and patients to overcome barriers to achieving guideline-recommended care is unknown.  We sought to characterize the potential roles of health information technology, multidisciplinary teams and financial incentives in achieving treatment goals for hypertension and hyperlipidemia in an emerging ACO.Methods: We conducted in-depth interviews with 20 primary care physicians (internal medicine or family medicine in an integrated network of independent community-based physician practices in the Greater Boston (Massachusetts) area. We used the immersion-crystallization approach to content analysis.Results: Physicians indicated that the most significant barriers to achieving treatment goals lie in the patient domain, rather than in those involving physician practice. The patient-physician relationship was cited as extremely influential in achieving treatment goals emphasizing the importance of a key component of person-centered medicine in this context. Health information technology and multi-disciplinary care (e.g., involving nurse practitioners) play supporting roles. Current financial incentives seem not to influence physicians’ management of these conditions.  Physicians generally agreed, albeit with some reservation, that electronic health records and computerized clinical decision support could support efforts to treat hypertension and hyperlipidemia; nonetheless, these physicians consistently reiterated the importance of a person-centered relationship with patients as a strong determinant of successful treatment.Conclusions: As ACOs emerge and organizations invest heavily in health information technology, multi-disciplinary care provision and financial incentives, it is essential that they also seize the opportunity to nurture patient-physician relationships in direct recognition of the importance of person-centered care in the optimization of clinical outcomes.

Article Details

Regular Articles
Author Biography

Roberta E Goldman, Alpert Medical School of Brown University

Clinical Professor of Family Medicine


McGlynn, E,A,, Asch, S.M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A. & Kerr, E.A. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine 348 (26) 2635-2645.

Shrank, W.H., Asch, S.M., Adams, J., Setodji, C., Kerr, E.A., Keesey, J., Malik, S. & McGlynn, E.A. (2006). The quality of pharmacologic care for adults in the United States. Medical Care 44 (10) 936-945.

Brown, L.C., Johnson, J.A., Majumdar, S.R., Tsuyuki, R.T. & McAlister, F.A. (2004). Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. Canadian Medical Association Journal 171 (10) 1189-1192.

Toth, E.L., Majumdar, S.R., Guirguis, L.M., Lewanczuk, R.Z., Lee, T.K. & Johnson, J.A. (2003). Compliance with clinical practice guidelines for type 2 diabetes in rural patients: treatment gaps and opportunities for improvement. Pharmacotherapy 23 (5) 659-665.

Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P.A. & Rubin, H.R. (1999). Why don't physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association 282 (15) 1458-1465.

Frolkis, J.P., Zyzanski, S.J., Schwartz, J.M. & Suhan, P.S. (1998). Physician noncompliance with the 1993 National Cholesterol Education Program (NCEP-ATPII) guidelines. Circulation 98 (9) 851-855.

Cook, S., Drum, M.L., Kirchhoff, A.C., Jin, L., Levie, J., Harrison, J.F., Lippold, S.A., Schaefer, C.T. & Chin, M.H. (2006). Providers' assessment of barriers to effective management of hypertension and hyperlipidemia in community health centers. Journal of Health Care for the Poor and Underserved 17 (1) 70-85.

Mosca, L., Linfante, A.H., Benjamin, E.J., Berra, K., Hayes, S.N., Walsh, B.W., Fabunmi, R.P., Kwan, J., Mills, T. & Simpson, S.L. (2005). National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation 111 (4) 499-510.

Karter, A.J., Parker, M.M., Moffet, H.H., Ahmed, A.T., Ferrara, A., Liu, J.Y., Selby, J.A. (2004). Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients. Medical Care 2 (2) 110-115.

Hickling, J., Rogers, S. & Nazareth, I. (2005). Barriers to detecting and treating hypercholesterolaemia in patients with ischaemic heart disease: primary care perceptions. British Journal of General Practice 55 (516) 534-538.

Dusing, R. (2006). Overcoming barriers to effective blood pressure control in patients with hypertension. Current Medical Research Opinion 22 (8) 1545-1553.

Cheng, H. (2006). Barriers for underuse of antihypertensive drug therapy for nursing home residents with hypertension. Journal of American Medical Directors Association 7 (6) 405-406; author reply 6.

Hroscikoski, M.C., Solberg, L.I., Sperl-Hillen, J.M., Harper, P.G., McGrail, M.P. & Crabtree, B.F. (2006). Challenges of change: a qualitative study of chronic care model implementation. Annals of Family Medicine 4 (4) 317-326.

Flottorp, S., Havelsrud, K. & Oxman, A.D. (2003). Process evaluation of a cluster randomized trial of tailored interventions to implement guidelines in primary care--why is it so hard to change practice? Family Practice 20 (3) 333-339.

Berenson, R. & Devers, K. (2009). Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandaries? Washington, DC: The Robert Wood Johnson Foundation. Available from:

Borkan, J. (1999). Immersion/crystallization. In: Doing Qualitative Research. (Crabtree, B. & Miller, W. eds.). Thousand Oaks, CA: Sage Publications; 1999.

Nair, K.V., Belletti, D.A., Doyle, J.J., Allen, R.R., McQueen, R.B., Saseen, J.J., Vande Griend, J., Patel, J.V., McQueen, A. & Jan, S. (2011). Understanding barriers to medication adherence in the hypertensive population by evaluating responses to a telephone survey. Patient Preference and Adherence 5, 195-206.

Martin, M.Y., Kohler, C., Kim, Y.I., Kratt, P., Schoenberger, Y.M., Litaker, M.S., Prayor-Patterson, H.M., Clarke, S.J., Andrews, S. & Pisu, M. (2010). Taking less than prescribed: medication nonadherence and provider-patient relationships in lower-income, rural minority adults with hypertension. Journal of Clinical Hypertension (Greenwich)12 (9) 706-713.

Bensing, J.M., Verheul, W., Jansen, J. & Langewitz, W.A. (2010). Looking for trouble: the added value of sequence analysis in finding evidence for the role of physicians in patients' disclosure of cues and concerns. Medical Care 48 (7) 583-588.

Martin, L.R., Williams, S.L., Haskard, K.B. & Dimatteo, M.R. (2005). The challenge of patient adherence. Therapeutic Clinical Risk Management 1 (3) 189-199.

Casebeer, L., Huber, C., Bennett, N., Shillman, R., Abdolrasulnia, M., Salinas, G.D., Zhang, S. (2009). Improving the physician-patient cardiovascular risk dialogue to improve statin adherence. BMC Family Practice 10, 48.

Braido, F., Baiardini, I., Menoni, S., Brusasco, V., Centanni, S., Girbino, G., Dal Negro, R. & Canonica, G.W. (2011). Asthma management failure: a flaw in physicians' behavior or in patients' knowledge? Journal of Asthma 48 (3) 266-274.