Barriers to Referral for Elevated Blood Pressure in the Emergency Department

描述（由申请人提供）：在急诊科（艾德）经常遇到未确诊的高血压（HTN）。少数民族和社会经济地位较低的人不成比例地受到HTN的影响，并且也不太可能获得足够的血压（BP）控制。虽然许多因素可能导致这种情况，但未能识别和转诊血压升高的患者构成了一个主要的公共卫生问题。鉴于未确诊的HTN的发病率和死亡率很高，了解医疗保健提供者的障碍是至关重要的，这些障碍可能导致缺乏对既往未确诊的HTN患者血压升高的重新评估和转诊。解决现有的文献差距，并确定这些障碍将最终指导未来的研究和积极的干预措施，可能是最有效的促使卫生保健提供者建议门诊随访。尽管已经提供了未转诊程度的文件，但尚未探讨可能导致各种艾德提供者（注册护士[RN]、执业护士[NP]、医生[MD]和医生助理[PA]）中既往未诊断HTN患者缺乏转诊的因素，也未将两种方法结合使用以充分阐明问题。因此，拟议研究的具体目标是：1）检查艾德提供者的障碍-对高血压预防、检测、评估和治疗联合国家委员会（JNC-7）和美国急诊医师学会（ACEP）建议的了解，对这些建议的态度和外部因素（患者、指南和环境因素[时间、资源和组织限制]）-与艾德提供者实践模式相关（血压升高患者的重新评估和/或转诊）;和2）根据JNC-7分类确定血压升高的患病率（HTN前[120-139/80-89 mm Hg]; 1期HTN [140-159/90-99 mm Hg]; 2期HTN e160/e100 mm Hg]），以及与艾德提供者实践模式相关的因素（血压升高患者的重新评估和/或转诊）。拟定研究将分为2部分。首先，为了解决目标1，将进行一项基于网络的横断面调查，旨在检查阻碍艾德提供者重新评估和/或转介血压升高患者进行进一步评估、管理和/或治疗的障碍。将完成一项回顾性病历审查，以检查目标2中血压升高的患病率以及与艾德提供者实践模式（血压升高患者的重新评估和/或转诊）相关的因素。该研究将在纽约市健康和医院公司（HHC）进行，该公司是美国最大的市立医院和医疗保健系统。该研究和拟议的研究培训计划将为申请人（少数族裔护士和家庭护士从业者）作为一名致力于健康差异研究的护理科学家的职业生涯做好准备。 公共卫生相关性：急诊科提供者可能有潜力减少未确诊的高血压的长期后果。检查可能影响这些提供者在就诊期间重新评估血压升高的知识，态度和外部因素形式的障碍，并将先前未诊断的HTN患者转诊，这对于实现这一目标至关重要。确定这些障碍将最终指导未来的研究，并有助于减少健康差距的努力。

DESCRIPTION (provided by applicant): 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. PUBLIC HEALTH RELEVANCE: 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.