70 Barriers to management of hypertension ORIGINAL PAPER

Providers Assessment of Barriers to Effective Management of Hypertension and Hyperlipidemia in Community Health Centers
Sandy Cook PhD Melinda L. Drum PhD Anne C. Kirchhoff MPH Lei Jin PhD Jessica Levie JD, MPH James F. Harrison MD Susan A. Lippold MD, MPH Cynthia T. Schaefer RN, CS Marshall H. Chin MD, MPH
Abstract: We explored 251 providers (47% licensed practical nurses, 27% registered nurses, 10% physicians, 10% physician assistants, 6% other) perceptions of barriers to effective management of hypertension and hyperlipidemia from 72 Midwest community health centers (CHCs). Optimal care for these diseases is difcult in any setting; little is known about the specic barriers CHCs face. Community health centers often have a multidisciplinary team that participates in patient care. Current models of quality improvement and chronic care management require virtually all CHC providers to know clinical guidelines. Providers in this study generally chose hypertension and hyperlipidemia target levels that met or were more stringent than national guidelines, but lacked condence to address behavioral change and reported obstacles to modifying patient lifestyle. Community health centers should strengthen providers skills in facilitating lifestyle change. Improving quality of care requires supporting providers efforts to take patients psychosocial and nancial challenges into account, and revised policies to eliminate nancial and cultural barriers to care. Key words: Barriers to management, community health centers, hypertension, hyperlipidemia, guidelines.

SANDY COOK is a Senior Education Specialist at the Chicago Diabetes Research and Training Center and is Associate Dean for Curricular Affairs at the University of Chicagos Pritzker School of Medicine. She can be reached at scook@uchicago.edu. Dr. Cook and MELINDA DRUM, ANNE KIRCHHOFF, LEI JIN, JESSICA LEVIE, and MARSHALL CHIN are all afliated with the Dept. of Medicine and Health Studies, or Diabetes Research and Training Center at the University of Chicago. At the time of the study JAMES HARRISON was afliated with the North Woods Community Health Center in Minong, Wisconsin; and SUSAN LIPPOLD was afliated with the Health Resources And Services Administration in Chicago. CYNTHIA SCHAEFER is afliated with the University Of Evansville in Evansville, Indiana. Dr. Harrison is currently with South Lane Medical Group, in Cottage Grove, Oregon and Dr. Lippold is currently with the Centers for Disease Control City of Chicago Tuberculosis Program.

Journal of Health Care for the Poor and Underserved 17 (2006): 7085.

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ypertension and hyperlipidemia are highly prevalent among Americans.14 These conditions are routinely under-detected and either untreated or poorly controlled, especially among vulnerable populations, such as African Americans and those of low socioeconomic status.515 In the United States, over 30% of chronic disease deaths come from heart disease. 3 Managing risk factors such as hypertension and hyperlipidemia can help to reduce the development of heart disease and other complications. Community health centers (CHCs) offer essential primary health care services to vulnerable populations living in rural and urban medically underserved communities16 and are fundamental to reducing health disparities between members of these communities and the general population.17 Health centers often provide care through a multidisciplinary team, where providers must know clinical guidelines to effectively participate in treatment. For example, in many centers, nurses develop selfmanagement goals for patients and assist primary care providers in the assessment and evaluation of patients. Also, CHCs are increasingly focused on improving quality of care through national efforts such as the Bureau of Primary Health Cares Health Disparities Collaborative, which aims to eliminate health disparities and change the way care is delivered. One fundamental piece of the Collaborative model is provider knowledge of clinical guidelines as a part of developing a prepared, proactive practice team [p. 1777],18 where nurses and other clinical staff play integral roles in education and self-management support of patients. With the focus on a team approach to care at CHCs, enhancing quality of care and health outcomes for patients at these centers requires intimate knowledge of the patient, provider, and system level factors that affect the provision of services. Given the prevalence and morbidity of hypertension and hyperlipidemia, understanding the barriers to providing optimal services for these conditions is vital to improve health outcomes for CHC patients. Studies conducted in various settings and populations describe specic barriers to effective hypertension and hyperlipidemia care. Barriers to hypertension care include providers non-adherence to recommended treatment guidelines and willingness to accept an elevated blood pressure level,19,20 as well as specic patient-related barriers such as social, economic and lifestyle impediments.21, 22 For hyperlipidemia, physician specialty and physician and patient demographics are related to underuse of lipidreducing therapies.9,23,24 Hypertension and hyperlipidemia treatment barriers for patients at CHCs are little explored. Therefore, we sought to identify barriers to the delivery of high quality hypertension and hyperlipidemia care within the CHC setting, ultimately to help CHCs develop interventions to improve care.

Methods
Study population. Due to the multidisciplinary team approach to care at CHCs, we surveyed a range of providers (licensed practical nurses, registered nurses, nurse practitioners, physicians, physician assistants, and others) who have responsibility for the care of patients with hypertension and hyperlipidemia at federally-funded CHCs associated with the MidWest Clinicians Network (MWCN). The MWCN is a nonprot corporation consisting of individual providers, community health centers,

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primary care associations, and other partners in 10 Midwestern states, coordinated by the Michigan Primary Care Association and open to all CHC clinical providers within those states. We invited the 145 federally funded CHCs who were members of the network in 2000 to provide a list of names of all providers who worked with patients with hypertension and hyperlipidemia. Ninety-four centers (65%) returned lists of names, and surveys were sent to 84 (58%) centers. The study population consisted of the 758 providers whose addresses were accurate at the time the survey was mailed. The University of Chicago Institutional Review Board approved the study. Survey development. The collaborative team of investigators from the MWCN, the Bureau of Primary Health Care, and the University of Chicago developed a 76-question survey to address potential major barriers to providing optimal care within the key barrier domains listed below. This survey was based on our earlier provider survey of the barriers to diabetes care in CHCs,25 as well as input from CHC providers during an annual meeting of the MWCN. During that meeting, interviews with providers working at CHCs identied the following types of barriers to quality improvement: Provider barriers: Lack of tracking and patient follow-up, lack of understanding of guidelines and the literature, controversy over guideline recommendations, lack of understanding of patient needs, and lack of training in facilitating behavioral change in patients; Patient barriers: Lack of adherence to referrals, asymptomatic nature of the diseases, linguistic and cultural difculties, psychosocial challenges blunting efforts to adhere, lack of patients acceptance of disease, and difculty of lifestyle changes; Practice/system barriers: Lack of multidisciplinary cooperation, documentation burdens, difculty educating patients at the right educational level, and difculty coordinating care with hospital. In further discussions, members of the MWCN Research Committee recognized that economic and nancial barriers, such as the expense of comprehensive care (including medications and diagnostic tests), inadequate reimbursement for educational services, insufcient time for providers to coordinate stafng, and lack of transportation, also have an impact on the practice of certain processes of care. Survey format. The rst portion of the survey asked providers to indicate their blood pressure and cholesterol goals for patients with varying cardiovascular risk factors. Providers were then queried about barriers to care through Likert-scale items with 5 response options (1=strongly disagree to 5=strongly agree). To facilitate responses, questions were grouped by content area: Medical Visits, Medications, Management, Lifestyle Factors (including diet, weight management, exercise, smoking cessation), and General Barriers to Care. Additional questions elicited responses from providers on the frequency with which certain psychosocial issues (such as competing health, environmental, nancial, and cultural needs) affected their patients abilities to manage their hypertension and hyperlipidemia (Likert-scale: 1=never,5 = all the time). Survey distribution. The 76 question survey was mailed to the 758 providers with up to 2 follow-up mailings for non-respondents. After the second follow-up

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mailing, a reduced version of the survey with a subset of 18 key questions was mailed to providers who had not yet responded. Statistical methods. Responses to survey items eliciting provider blood pressure and cholesterol goals for patients with different risk factor levels were classied according to their agreement with the Sixth Report of the Joint National Committee of Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI)26 and Third Report of the National Cholesterol Education Program (NCEP)27 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) guidelines. While NCEP II guidelines28 were in force at the time of the initial mailing, NCEP III guidelines, which were released midway through the collection of the surveys, were the ones used to measure the performance rates. The only difference between NCEP II and NCEP III relevant to this survey is that presence of diabetes as a comorbidity led to a target LDL of 130 mg/dL in NCEP II versus 100 mg/dL for NCEP III.27 Rates of agreement of blood pressure and lipid goals with guideline recommendations were calculated with 95% condence intervals. Rates are reported both for goals that were at or below the guidelines and for goals that were in exact agreement with the guidelines. Responses to survey items assessing barriers to optimal care were dichotomized as agree/ strongly agree versus lower ratings due to the discreteness of the Likert response scale (1 = strongly disagree, 5 = strongly agree) and the typical skewness of responses. Summary scales were constructed as averages of items belonging to 10 specic survey domains (Table 1). Reliability of summary scales was assessed using Cronbachs alpha (range: .59.95). The summary scales were then dichotomized to correspond to the original Likert scale, using 3.5 as the cutpoint between agree/strongly agree and lower ratings. Rates of agreement were calculated with 95% condence intervals, and the effect of urban versus rural location on rates of agreement was tested. Differences in responses to a limited number of related items, such as importance of medical versus lifestyle management, were also tested. All analyses incorporated the hierarchical structure of the data arising from nesting of providers within health centers by utilizing GEE (generalized estimating equation) linear and logistic regression29 for continuous and dichotomous responses, respectively. Rates of agreement were estimated by regression on intercept only; urban location was then added as a covariate to test the effect of urban versus rural location on the response. The association between related responses was evaluated by regressing the rst response on the second. When clustering is not present, the GEE models used are equivalent to ordinary linear and logistic models. In particular, regression on intercept only yields the usual point estimates and condence intervals for means and proportions.

Results
Survey response and respondents. We received 251 (33%) surveys from 72 (89%) centers (219 full form, 32 reduced form). Forty-seven percent of respondents were licensed practical nurses; 27% were registered nurses; 10% were physicians, and 10% were physician assistants. The remaining 6% were administrators, dietitians, health educators, and other health care professionals. The respondents with clinical

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Table 1.
BARRIERS SUMMARY SCALES
Summary Scale Number of items 4a 4a 3b 4c 4d 4c 3e 4c 4c 4c

Condence in knowledge of medical management of hypertension. Condence in knowledge of medical management of hyperlipidemia. Importance of medical management provider rating. Importance of lifestyle modication provider rating. Importance of medical management provider rating of patient perception. Importance of lifestyle modication provider rating of patient perception Responsibility for teaching medical management. Responsibility for teaching lifestyle change. Condence in ability to teach lifestyle change. Condence in ability to change patients lifestyle behavior.
a

When to prescribe medications, which medications to prescribe, complications of medications, appropriate diagnostic tests b Regular medical visits, taking medications as prescribed, reporting side effects c Diet, exercise, weight management, smoking cessation d Regular medical visits, taking medications as prescribed, taking medications in absence of symptoms, reporting side effects e How to take medications, side effects of medications, barriers to adherence to medical regimen

responsibilities reported a mean (sd) of 37(11) hours per week at their clinics and 32(13) hours in direct patient care. On average, they cared for 34(29) hypertension and 29(26) hyperlipidemia patients per week. There were 139 respondents from 40 urban health centers and 112 respondents from 32 rural health centers. Provider roles and barriers. Knowledge of treatment guidelines. A large majority of respondents reported blood pressure and cholesterol goals that either met or were more stringent than the guidelines for each clinical scenario (Table 2). The lowest rates of respondent agreement were for the 130/85 mm Hg blood pressure goal for patients with hypertension and diabetes, and the 100 mg/dL LDL goal for patients with hyperlipidemia and diabetes. However, almost all respondents matched or were more stringent than the less strict NCEP II LDL goal of 130 mg/dL that was in effect at the time of the rst mailing of the survey. A large proportion of providers reported more stringent goals than set by the guidelines for three scenarios (blood pressure among hypertensive patients, LDL cholesterol for patients with hyperlipidemia, LDL cholesterol for patients with two cardiovascular risk factors) so that exact agreement in these cases was low. Medical management and management behaviors. Most providers agreed that they were condent in their knowledge of medical management for both hypertension and hyperlipidemia (Table 3). Similarly, most providers agreed on the importance of lifestyle modication and medical management (regular medical visits, taking medications, and reporting side effects) (Table 3, Figure 1). There were no signicant differences between urban and rural respondents in these areas.

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Table 2.
PERCENT OF RESPONDENTS WHO MATCHED BLOOD PRESSURE AND CHOLESTEROL GOALS FROM JNC VIa AND NCEP III GUIDELINESb
Percent of Providers (95% C.I.) Management Area Patient Subgroup Blood Pressure Hypertension, without other cardiovascular risk factors Hypertension, with diabetes Total Cholesterol Hyperlipidemia, without other cardiovascular risk factors LDL Cholesterol Hypercholesterolemia, without other cardiovascular risk factors Hyperlipidemia, with diabetes, but no other cardiovascular risk factors Hyperlipidemia, with two other cardiovascular risk factors Hyperlipidemia, with known coronary artery disease
a

Guideline Goal

At Goal

At/Below Goal

140/90 mm/Hg 130/85 mm/Hg

41 (35,47) 17 (13,22) 84 (79,88) 27 (22,33) 71 (65,77) 29 (23,36) 81 (75,86)

93 (89,95) 70 (65,74) 92 (87,95) 99 (96,99.6) 74 (68,79) 96 (93,98) 87 (82,91)

200 mg/dL

160 mg/dL 100 mg /dL 130 mg/dL 100 mg /dL

Anonymous. The sixth report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Int Med. 1997 Nov 24;157(21):241346. b National Cholesterol Education Program. Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), Executive Summary. Bethesda, MD: National Heart Lung and Blood Institute, 2001.

Instruction of patients. The majority of providers agreed that it was their responsibility to teach patients lifestyle modication and medical management, including how to identify barriers to adherence (Table 3, Figure 2). Agreement with responsibility for teaching medical management was signicantly higher than with responsibility for teaching lifestyle change (p<.001). Overall, a majority of providers agreed that they were condent in their ability to instruct patients on lifestyle modication, but fewer were condent in their ability to change patients behavior (p<.001). Urban and rural respondents did not differ signicantly regarding patient instruction. Providers perceptions of patient barriers. Importance of management behaviors. In contrast to their own ratings of importance of medical adherence and lifestyle modication, few providers agreed that patients believe these behaviors to be

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Table 3.
PERCENT OF RESPONDENTS WHO AGREED ON MEDICAL MANAGEMENT AND LIFESTYLE MODIFICATION FOR PATIENTS WITH HYPERTENSION AND HYPERLIPIDEMIAa
Provider Agreement Percent (95% C.I.) Medical management Condent in knowledge of medical management of hypertension. Condent in knowledge of medical management of hyperlipidemia. Importance of patient management behaviors Medical management Lifestyle modication Instruction of patients Responsibility to teach medical management Responsibility to teach lifestyle modication Condent in ability to teach lifestyle change -if agreed on responsibility to teach Condent in ability to effect lifestyle change -if condent in ability to teach Patient barriers Importance to patients -medical management -lifestyle modication Adherence difculty -medication adherence -lifestyle modication Provider barriers (practice/system level) Lack of time to teach medical adherence Lack of time to teach lifestyle modication -if agreed to responsibility to teach Adequate resources for lifestyle instruction -if agreed to responsibility to teach
a

81 82 96 95 93 82 59 73 35 55

(.73,.87) (.75,.88) (.93,.98) (.92,.97) (.89,.96) (.76,.86) (.52,.65) (.65,.79) (.29,.42) (.48,.63)

41 21 28 75 72 59 62 23 22

(.34,.47) (.17,.27) (.22,.35) (.69,.81) (.66,.78) (.52,.65) (.55,.69) (.17,.31) (.16,.31)

Barriers summary scales. Items contributing to the scales are described in Table 1. Responses to individual items comprising the scales are summarized in Figures 14.

important for managing hypertension and hyperlipidemia (Table 3, Figure 1). Fewer than half of providers agreed that patients consider medical management important, and even fewer agreed that patients consider lifestyle modication important. In addition, providers at urban health centers were less likely than those at rural locations to agree that their patients consider taking medications important (Table 4).

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Figure 1. Providers Beliefs in Importance of Medical Management and Lifestyle Modication Behaviors.

Figure 2. Providers Responsibility, Confidence, and Resources for Teaching Lifestyle Modication and Medication Usage.

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Table 4.
DIFFERENCES BETWEEN URBAN AND RURAL RESPONDENTS IN LEVEL OF AGREEMENT ON MEDICAL MANAGEMENT AND LIFESTYLE MODIFICATION ISSUES FOR PATIENTS WITH HYPERTENSION AND HYPERLIPIDEMIAA
Provider agreement: Urban (%) Rural (%) Odds Ratio (95% CI) P valuea

Important to patients Taking medications - in general - when no symptoms Responsibility to instruct Smoking cessation Patient barriers Adherence to exercise - safety a barrier - disability a barrier Financial - special diets - weight management - exercise Psychosocial - overall - personal and family - environmental - psychological - cultural
a

46 23 72

58 36 81

.61 (.35,1.07) .53 (.31,.91) .59 (.32,1.07)

.083 .021 .084

49 36 55 48 57 79 78 73 65 59

25 24 26 31 44 57 58 50 41 43

2.96 (1.55,5.64) 1.77 (.97,3.23) 3.49 (1.92,6.33) 2.10 (1.23,3.61) 1.71 (.98,3.00) 2.85 2.47 2.67 2.67 1.93 (1.59,5.09) (1.31,4.69) (1.42,5.01) (1.59,4.49) (1.09,3.41)

.001 .063 <.001 .007 .061 <.001 .006 .002 <.001 .024

Results are presented for responses that differed between urban and rural providers at signicance level p<.10.

Difculty of adherence. A large majority of providers indicated that the complexity or challenges of the behavioral aspects of effective management created barriers for their patients (Table 3, Figure 3). Taking medication as prescribed was not judged to be as complex or difcult as lifestyle modication. A substantial minority of providers reported that disability, lack of time, and safety concerns hindered patients efforts to exercise. Urban providers were more likely than rural providers to consider safety and disability to be barriers to exercise for their patients (Table 4). Financial barriers. Many providers reported that nancial problems, such as lack of employment or health insurance, frequently affect their patients ability to manage their hypertension and hyperlipidemia effectively. More specically, a majority agreed that their non-Medicaid patients could not afford their medications. Fewer providers considered costs of medical visits, special diet, weight management, or

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Figure 3. Providers Perceptions of Patient Barriers to Management of Hypertension and Hyperlipidemia.

exercise to be obstacles (Figure 3). Providers at urban health centers were more likely than those at rural locations to consider costs of lifestyle modication problematic for their patients (Table 4). Psychosocial barriers. A majority of providers reported that psychosocial factors considerably affect their patients ability to manage their hypertension and hyperlipidemia successfully (Figure 4). Personal and family matters (e.g., lack of family support, overwhelming family responsibilities, domestic violence) were considered problematic by the largest proportion of providers. A majority of providers also considered the impact to be substantial for psychological factors (e.g., depression, limited intellectual functioning, substance abuse), competing health conditions (e.g., diabetes, asthma), environmental factors (e.g., limited transportation, limited access to healthier foods, neighborhood violence), and cultural factors (e.g., attitudes about medication, dietary practices, religious beliefs, ethnic and family customs). More urban respondents reported that psychosocial barriers affected their patients ability to manage their hypertension or hyperlipidemia (Table 4), with no signicant difference between urban and rural respondents. Practice/system barriers. Time and resources. A large majority of providers agreed that nding time to teach about the importance of adherence to the medical regimen was a barrier to effective care; over half reported that lack of time was a barrier to instruction on lifestyle modication, while fewer than 25% agreed that resources for instruction in their health center were adequate (Table 3).

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Figure 4. Providers Perceptions of Impact of Psychosocial Factors on Management of Hypertension and Hyperlipidemia.

Discussion
This survey identied key barriers and systemic impediments that health center providers face while caring for their patients. Prior studies suggest several factors that result in lower adherence to hypertension and hyperlipidemia treatment guidelines among generalist physicians. These include complex and changing clinical guidelines, a lack of physician knowledge of these guidelines, and a lack of compliance.3033 Unlike previous studies, ours found that the CHC providers generally selected target blood pressure and lipid levels that were at or below recommended clinical guidelines. Certain providers, such as the licensed practical nurses (LPNs) who provided the largest proportion of our responses, traditionally may not be expected to know clinical guidelines, although, with the multidisciplinary nature of care at CHCs and the increasing focus on quality improvement, staff at all levels are being educated about them. In fact, nurses and medical assistants often work with patients to set self-management goals; and in many centers, these types of providers are empowered to remind primary care providers of specic labs and referrals needed to adhere to clinical guidelines. Therefore, adequate guideline knowledge by all providers is part of the commitment CHCs have made to providing comprehensive care. We did nd that for some of the clinical scenarios described on the survey, agreement was low, which may indicate a remaining knowledge gap among some

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provider types. Specically, relating to the blood pressure goal of 130/85 mm Hg for patients with hypertension and diabetes (or, even more stringently, 130/80 mm Hg, as currently recommended by the American Diabetes Association)34 and for the revised LDL goal of 100 mg/dL for patients with hyperlipidemia and diabetes. This discrepancy with the LDL guideline is difcult to interpret due to the change in the NCEP guidelines over the course of the study. The belief of providers that their patients do not think certain components of hypertension and hyperlipidemia care are important may affect the way they treat and communicate with their patients. Effective patient-provider communication and agreement about treatment are associated with improved treatment adherence, self-management skills, and enhanced health outcomes.35,36 Providers with pessimistic beliefs of their patients attitudes may inadvertently convey lower expectations to their patients and fail to involve patients in developing self-treatment goals. If patients believe medication or lifestyle adherence is important, but see these facets of care disregarded by their providers, this may lead to distrust or decreased communication. Since patients who do not trust or have good communication with their providers are less likely to feel they are receiving services they need,37 gaining a better understanding of why providers think their patients often do not adhere to their hypertension and hyperlipidemia treatment plans is essential to improving care. While it is difcult to determine whether our providers perceptions represent an over- or underestimation of patients actual beliefs, it is critical to understand whether the providers assessments truly reect their patients beliefs and, if not, why the gap exists and what effect it may have on effective communication and health care outcomes of their patients. Discovering why urban and rural providers differ regarding patients assessment of medication importance would contribute to understanding this issue. Providers in this survey considered their responsibility for teaching medical compliance greater than their responsibility for teaching lifestyle change, which also may have an effect on patient adherence to diet, weight management, smoking cessation, and exercise treatment recommendations. Additionally, few providers were condent in their ability to change patients behaviors. Other studies cite a lack of patient adherence to medication regimens as a major barrier to good cardiovascular care.3841 Providers need the skills to promote both medical adherence and lifestyle change as necessary actions for hypertension and hyperlipidemia treatment in their patients. In a recent study of a physicians group, time was not deemed an important barrier to making needed changes in hypertension medication.19 In CHCs, however, time and other system barriers may be more salient than in private health care groups. Providers in our study reported insufcient time to educate patients, inadequate resources to promote lifestyle behavior change, and negative effects of patients nancial status on hypertension and hyperlipidemia management. Research examining how CHCs organizational structure and the economic status of patients inuence clinical care and outcomes is critical for the development of effective health care policies. The 33% survey response rate, while reasonable for busy providers in resourceconstrained situations, may limit the generalizability of our ndings due to selection

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bias. In particular, providers knowledge of national guidelines for the care of patients with hypertension and hyperlipidemia may be overestimated, because responding providers may be those who are more likely to stay apprised of current recommendations. The other major ndings regarding the challenges of lifestyle changes, resource constraints, nancial problems, and psychosocial problems are likely to be valid, as we found analogous results in the survey we performed of health center providers regarding diabetes management with 72% response rate.25 Also, since guidelines are updated, we used the more stringent NCEP III hyperlipidemia guidelines that were released during the study as the benchmark standard.42 This choice may partially counteract a selection bias of respondents who were aggressive about treating high cholesterol. Despite these possible limitations, our survey supplies important information regarding the types of barriers impeding quality improvement efforts for cardiovascular care in CHCs. In addition, we recommend further research on targeted interventions that go beyond the mere dissemination of knowledge. These interventions must strive to change behavior of both providers and patients and improve the organizational systems that affect management of chronic diseases. Interventions that encourage patients to play a more active role in their hypertension and hyperlipidemia care, accompanied by programs that increase providers condence in their ability to help bring about behavior change in their patients, may be helpful. In addition, as our providers believed nancial and psychosocial barriers impaired patients ability to manage their hypertension and hyperlipidemia, programs to assist providers, health centers, and patients address those issues may also improve patient outcomes. Quality improvement initiatives can only succeed if we understand the circumstances that give rise to barriers. Lastly, improving hypertension and hyperlipidemia care at the CHC population level requires a comprehensive review of health care policies and reimbursement, as well as consideration of the CHC organizational structure. One recent intervention that recognizes the role of the larger organizational structure in changing and improving the clinic delivery system is the BPHCs Health Disparities Collaborative. Using the Chronic Care Model and a system of rapid change (Plan-Do-Study-Act (PDSA)) cycles for continuous quality improvement, the BPHC has helped CHCs examine broad systems issues and improve the quality of care.43,44 One lesson they have learned is that while it is possible to make systemic changes,45 it is challenging to sustain them. Future research must focus not only on acknowledging and understanding patient, provider, and system level barriers to care, but on nding ways to incorporate long-term solutions to these barriers into the culture and nancial environment of community health centers.

Acknowledgments
This project was supported by the Bureau of Primary Health Care / Agency for Healthcare Research and Quality (6 H68 CS 0013515 S5 R5), and the National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and Training Center (P60 DK20595). Dr. Chin was a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar.

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This paper was presented in part at the Midwest Society of General Internal Medicine annual meeting, September 28, 2002, Chicago, Illinois.

Notes
1. National Center for Health Statistics (NCHS). Health, United States, 2002. (DHHS Pub. No. 1232.) Hyattsville, MD: NCHS, 2002. Available at http://www.cdc.gov/nchs/ data/hus/hus02.pdf. Sempos CT, Cleeman JI, Carroll MD, et al. Prevalence of high blood cholesterol among US adults. An update based on guidelines from the second report of the National Cholesterol Education Program Adult Treatment Panel. JAMA. 1993 Jun 16;269(23):300914. National Center for Chronic Disease Prevention and Health Promotion. The burden of chronic disease and their risk factors, 2002. Atlanta, GA: Centers for Disease Control and Prevention, 2002. http://www.cdc.gov/nccdphp/burdenbook2002/index.htm. Gardner CD, Winkleby MA, Fortmann SP. Population frequency distribution of nonhigh-density lipoprotein cholesterol (Third National Health and Nutrition Examination Survey [NHANES III], 19881994). Am J Cardiol. 2000 Aug 1;86(3):299304. Doyle DB, Lauterbach W, Samargo P, et al. Age- and sex-biased underdetection of hypertension in a rural clinic. Fam Pract Res J. 1991 Dec;11(4):395404. He J, Muntner P, Chen J, et al. Factors associated with hypertension control in the general population of the United States. Arch Intern Med. 2002 May 13;162(9):10518. Ford ES, Mokdad AH, Giles WH, et al. Serum total cholesterol concentrations and awareness, treatment, and control of hypercholesterolemia among US adults: ndings from the National Health and Nutrition Examination Survey, 1999 to 2000. Circulation. 2003 May 6;107(17):21859. Pavlik VN, Hyman DJ, Vallbona C. Hypertension control in multi-ethnic primary care clinics. J Hum Hypertens. 1996 Sep;10 Suppl 3:S1923. Stafford RS, Blumenthal D, and Pasternak RC. Variations in cholesterol management practices of U.S. physicians. J Am Coll Cardiol. 1997 Jan;29(1):13946. Cohen MV, Byrne MJ, Levine B, et al. Low rate of treatment of hypercholesterolemia by cardiologists in patients with suspected and proven coronary artery disease. Circulation. 1991 Apr;83(4):1294304. McBride P, Schrott HG, Plane MB, et al. Primary care practice adherence to National Cholesterol Education Program guidelines for patients with coronary heart disease. Arch Intern Med. 1998 Jun 8;158(11):123844. Lai LL, Poblet M, and Bello C. Are patients with hyperlipidemia being treated? Investigation of cholesterol treatment practices in an HMO primary care setting. South Med J. 2000 Mar;93(3):2836. Jacobson TA, Grifths GG, Varas C, et al. Impact of evidence-based clinical judgment on the number of American adults requiring lipid-lowering therapy based on updated NHANES III data. National Health and Nutrition Examination Survey. Arch Intern Med. 2000 May 8;160(9):13619. Massing MW, Foley KA, Sueta CA, et al. Trends in lipid management among patients with coronary artery disease: has diabetes received the attention it deserves? Diabetes Care. 2003 Apr;26(4):9917. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001 Aug 16;345(7):47986.

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