Deprescribing Pro Re Nata Antihypertensives in the Hospital An Implementation Science Pilot Study Based on the COM-B Framework

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Deprescribing Pro Re Nata Antihypertensives in the Hospital An Implementation Science Pilot Study Based on the COM-B Framework Anthony Fangman , View ORCID Profile Srilatha Gannavaram , Mark Steinbeck , Rebecca Adler , Abdul Wali Khan , View ORCID Profile Zhuxuan Fu doi: https://doi.org/10.1101/2025.08.18.25333937 Anthony Fangman * Hospital Medicine Division, Saint Luke’s Physicians Group MD, MBA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Srilatha Gannavaram * Hospital Medicine Division, Saint Luke’s Physicians Group MD, MS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Srilatha Gannavaram For correspondence: sgannavaram{at}saint-lukes.org Mark Steinbeck ^ Pharmacy Division, Saint Luke’s Health System RPh,MBA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Rebecca Adler + Department of Internal Medicine, University of Missouri Kansas City School of Medicine DO Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abdul Wali Khan + Department of Internal Medicine, University of Missouri Kansas City School of Medicine MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Zhuxuan Fu # Biostatistics, Saint Luke’s Research Administration PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Zhuxuan Fu Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Elevated blood pressure is a common occurrence in acute care settings irrespective of the reason for hospitalization. A large body of available evidence suggests possible harm from intensive hypertension management when there is no evidence of end-organ damage, otherwise known as asymptomatic hypertension (HTN). Despite this, Pro Re Nata (PRN) antihypertensives are commonly prescribed to hospitalized adults and utilized to treat asymptomatic hypertension. This practice contributes to patient harm and is considered low value care. So far, there is limited evidence to guide interventions that can successfully and consistently deprescribe PRN antihypertensive use in acute care settings. To address this gap, we conducted a pilot study in which we developed an intervention bundle using implementation science concepts based on the COM-B framework. Our results showed a significant decrease in the use of PRN antihypertensive prescriptions for hospitalized adults by hospitalist providers, especially following the delivery of high-fidelity interventions, This pilot was conducted in a single health care system comprising multiple hospitals. Due to their low cost and easy adaptability, we believe that the methods described here can be reproduced widely to minimize patient harm and allow ongoing evaluation of practices to address elevated blood pressure in acute settings. Further, this study demonstrates the feasibility of integrating implementation science principles into responsible management of hypertension among hospitalized adults based on available evidence. INTRODUCTION Hypertension is a chronic disease condition among adults and a well-recognized risk factor for various adverse health outcomes including coronary artery disease, stroke, renal disease, and increased mortality ( 24 , 25 ). In primary care, appropriate recognition of this condition and evidence-based treatment have proven benefits in improving health outcomes ( 24 , 25 ). On the other hand, treatment of hypertension in the inpatient setting is much more complicated due to the lack of established guidelines ( 23 ). Multiple studies in fact demonstrated harm when HTN is aggressively treated in the hospital except when a hypertensive crisis with end-organ damage is present ( 2 - 6 , 8 , 10 , 12 - 14 , 18 ). The reasons for such disparity in outcomes between ambulatory and acute settings are likely to be multifold. Possible factors include spurious blood pressure elevations, inappropriate timing and/or technique of blood pressure measurements, IV fluids, fluid overload, glucocorticoids or other treatments that could transiently raise blood pressure, missed home medications, patient anxiety, inadequate pain control, adrenergic response associated with acute illnesses and others that are yet to be identified ( 15 - 17 ). Therefore, it is very important to distinguish between asymptomatically elevated blood pressures and hypertensive emergencies among hospitalized adults. The former requires an assessment of causes followed by a tailored treatment plan whereas the latter requires initiation of immediate treatment with established protocols based on the type of end-organ damage ( 5 ). Scientific statement from American Heart Association states that asymptomatically elevated blood pressure in the inpatient setting should not be treated routinely ( 13 ). Most importantly, PRN antihypertensive use has been linked to patient harm and adverse effects including hypotension, acute kidney injury, strokes, increased length of stay and mortality among hospitalized adults ( 2 - 6 , 8 , 10 , 12 - 15 , 18 ). The prevalence of elevated blood pressure in adult medical inpatients has been estimated to be as high as 72% ( 1 ). However, only 0.6% of patients that present to acute care facilities without evidence of end-organ damage are estimated to have a hypertensive emergency ( 5 ). Despite this, the use of PRN antihypertensives remains a widely prevalent practice affecting an estimated 21-35% of all hospitalized adults ( 13 , 28 ). Routine prescriptions for PRN antihypertensives in the hospital are problematic for three reasons. First and foremost, blood pressure is treated without giving providers an opportunity to assess whether end-organ damage is present, potentially leading to inappropriate treatment of hypertensive emergencies. Secondly, asymptomatically elevated blood pressures are aggressively treated, increasing patient risk. Lastly, this practice results in an increased utilization of low value care and high costs associated with unnecessary treatment. A prior Quality Improvement initiative by hospitalist providers successfully decreased the use of IV Hydralazine and Labetalol among patients with elevated blood pressures without increasing patient harm ( 11 ). In our study, we sought to expand these interventions, broaden the number of PRN antihypertensives targeted, and aimed to avoid extensive patient-level data acquisition in order to increase adaptability among various acute care facilities. To this end, we used implementation science concepts based on the COM-B framework that included assessment of barriers followed by the development of an intervention bundle. Our primary outcome measure was a reduction in the percentage of patients with prescriptions for PRN antihypertensives. Additional outcome measures were a reduction in the total number of PRN antihypertensive orders by hospitalist providers, a sustained change in provider prescribing patterns and responsiveness of outcomes to the fidelity of interventions. We also monitored the use of medication orders to treat hypertensive emergencies, and deaths among patients treated for hypertensive emergencies to measure the potential for unintended harms associated with a reduction in antihypertensive medications. METHODS As we considered interventions that can be successfully implemented and sustained, we sought to identify those that involved no cost or low cost to the hospitalist division and the health system, use Electronic Health Record (EHR) data to which our hospitalist division has ready access and avoid collection of extensive patient-level data. The study was conducted in all Saint Luke’s Health System (Barnes Jewish West Region) hospitals where hospitalists manage patients. Stakeholders for the study were all hospitalist providers within the health system. We received a Quality Improvement determination from our Internal Review Board. We used the COM-B framework, and the Behavior Change Wheel ( 27 ) to perform a barrier assessment. Per semiformal communications with hospitalist providers and a priori knowledge, the following barriers were identified for de-implementation of PRN antihypertensives in the acute care setting: Provider lack of knowledge regarding potential harms of aggressive treatment of asymptomatic HTN. Provider reluctance to change practice due to perceived harm to patients caused by elevated blood pressure. Nursing expectations for providers to place PRN orders when blood pressure is elevated. Inadequate time for providers to consider alternative explanations and develop a tailored treatment plan. Provider desire to maintain autonomy over patient-care decisions regarding blood pressure management. Provider aversion to frequent Best Practice Advisory (BPA) alerts built into Electronic Health Record (EHR). Following barrier assessment, we identified three intervention areas-Education, Environmental restructuring and Persuasion to develop the following intervention bundle. Intervention Bundle 1 – Education Consisted of (i) group education and (ii) tailored education to providers with PRN antihypertensive orders higher than group average. Intervention Bundle 2 - Environmental restructuring Consisted of (i) updating hospitalist admission order set with a higher blood pressure threshold for nursing staff to alert providers if patients did not have new symptoms and (ii) engaging nursing leadership to influence nursing expectations for PRN antihypertensives. Formal nursing education was not provided. Intervention Bundle 3 – Persuasion Consisted of two audit and feedback interventions and reminders. We collected monthly data on the number of PRN antihypertensive orders generated by individual hospitalist providers. This data was used to provide (i) feedback by site (number of orders generated at each hospital site were shared with all providers at that site), (ii) targeted feedback by provider (providers prescribing higher than group average were sent tailored education). Providers identified for targeted feedback were made aware that their PRN antihypertensive use was higher than the group average. They were provided with links to relevant scientific literature. In addition, they were informed that chart reviews were not done, and that the appropriateness of prescriptions has been deferred to individual providers caring for patients. Lastly, reminders were provided to all hospitalist providers regarding the reasons we were undertaking these interventions. We utilized a quasi-experimental interrupted time series design with our research plan being carried out over six periods including baseline as described below. Each period consisted of three consecutive months. June 2023-August 2023 (Baseline) - No intervention . Retrospective data collection. Sept 2023-November 2023 (Period 1) - Intervention: General provider education . All providers in the hospitalist division of our health system were provided education about potential harms of using PRN antihypertensives. January 2024-March 2024 (Period 2) - Intervention: Environmental restructuring . See above for description. April 2024-June 2024 (Period 3)-Intervention: Audit and feedback by site . See above for description. July 2024-September 2024 (Period 4) - Intervention: Audit and targeted feedback (tailored education) . See above for description. October 2024-December 2024 (Period 5) - No intervention . Ongoing monthly data collection. Fidelity to various interventions varied from medium to high, as indicated in Table 1 . Listed interventions were carried out in addition to modeling targeted behavior by medical directors and selected senior partners in the group which was ongoing prior to and throughout the study period. View this table: View inline View popup Download powerpoint Table 1: Interventions by period and fidelity to each intervention All data points were extracted using the Slicer Dicer function in our health system’s EHR, Epic. Data was then exported to Microsoft Excel with security features and analyzed. OUTCOMES We collected the following data to monitor outcomes. All data were collected at the end of each period except #1, which was collected monthly. Number of PRN antihypertensive orders by site and by provider for the following medications IV Hydralazine, PO Hydralazine, IV Labetalol, PO Clonidine, IV Enalaprilat. Number of orders for the following infusions to treat HTN emergency (not limited to orders by hospitalist providers). Esmolol, Nicardipine, Nitroglycerin, Phentolamine and Sodium Nitroprusside. Number of deaths among patients that received an infusion for HTN emergency. Number of unique patient encounters by hospitalist providers The above data was analyzed to evaluate changes in the percentage of patients with PRN antihypertensive orders, overall numbers and distribution of PRN antihypertensives, provider prescribing patterns, effects on the number of infusions ordered for hypertensive emergencies and deaths among patients that received at least one infusion for hypertensive emergency. Percentage of PRN antihypertensives per patient encounter The number of unique hospitalist encounters for each period during the study varied from 8883 to 9909. The percentage of encounters with PRN antihypertensive medication orders was calculated using this data combined with PRN antihypertensive orders data. We found that the percentage of encounters with PRN antihypertensive orders decreased from 14.7% at baseline to 2.7% in period 5, with the most significant reduction occurring in the use of IV Hydralazine from 10.5% of patient encounters to just 0.74%. These results reflect a substantial reduction in the percentage of patients treated by hospitalists that had prescriptions for PRN antihypertensives. Individual Provider PRN antihypertensive prescribing patterns Prescription patterns of individual providers were analyzed, omitting those providers that were not present for the entirety of the study period. Each of these ninety-two providers were placed in one of five groups based on the number of PRN antihypertensive orders during the preceding period. The groups were (i) Extremely high: greater than 50 orders, (ii) High: 21-50 orders, (iii) Moderate: 11-20 orders, (iv) Low: 6-10 orders and (v) Minimal: Less than 5 orders. At baseline, there were two providers in the extremely high group, fifteen in the high group, thirty-eight in the moderate group, seventeen in the low group and twenty in the minimal group. At the end of period five, none of the providers were in extremely high or high groups. One provider was in the moderate use group; seven providers were in the low use group and the remaining eighty-four providers were in the minimal use group ( Table 2 ). We observed a reduction in the number of providers in the high, moderate and low use groups following high-fidelity interventions (order set modification, audit and feedback) in the period preceding data collection. The number of providers in the minimal use category increased following the delivery of high-fidelity interventions in the period preceding data collection ( Figure 1 ). View this table: View inline View popup Download powerpoint Table 2: Provider groups by period Download figure Open in new tab Figure 1: Provider grouping following high fidelity interventions Effects on the number of total PRN antihypertensives During the baseline period, 1329 PRN antihypertensive orders were placed by hospitalist providers. For the subsequent two periods of 3 months each, a slight reduction of overall PRN antihypertensives and IV hydralazine was noted. Substantial reductions were noted in both overall PRN antihypertensive use and IV hydralazine use in periods 3 through 5 ( Table 3 ). View this table: View inline View popup Download powerpoint Table 3: PRN antihypertensive order trends Effects on the distribution of PRN antihypertensive orders IV Hydralazine was the predominant PRN antihypertensive in the baseline and subsequent two periods, accounting for 71.5%, 65% and 58.8% of overall PRN antihypertensives, respectively. In period 3, IV hydralazine decreased to 46.1% and further decreased in periods 4 and 5 to 22.7% and 26.9% respectively. IV labetalol percentage rose from 17.9% at baseline to 47.6% of the overall PRN antihypertensives in period 5, becoming the most common PRN IV antihypertensive prescribed by hospitalist providers at the end of period 5 ( Figure 2 ). A review of the total number of these prescriptions demonstrates that while the percentage of labetalol use increased, the overall number of orders decreased from 238 in baseline period to 131 in period 5. Download figure Open in new tab Figure 2: Number and types of PRN antihypertensive orders by period Treatment of Hypertensive Emergencies We collected data on the number of infusions and medications used for hypertensive emergencies throughout our health system for the study period. These included Esmolol, Nicardipine, Nitroglycerin, Phentolamine, and Sodium Nitroprusside. We excluded procedural use of these medications and included their use in any department or any provider, not limiting use by hospitalist providers. Our results showed that despite a conservative approach to hypertension management, there was a reduction in the overall use of medications administered for hypertensive emergency treatment ( Table 4 ). A review of the number of deaths that occurred among patients that received one or more of these medications for hypertensive emergency management did not show meaningful change. View this table: View inline View popup Download powerpoint Table 4: Number of Infusions to treat HTN emergencies DISCUSSION Elevated blood pressure is a common occurrence among hospitalized patients. Many of these patients do not have evidence of end-organ damage yet frequently receive treatment with PRN antihypertensives that are administered based on blood pressure values alone. This practice can increase patient harm as a large body of observational data has shown that the use of PRN antihypertensives can increase the risk of adverse patient outcomes. Use of PRN antihypertensives without appropriate evaluation to assess the presence of end-organ damage may lead to undiagnosed incidences of hypertensive emergencies. In addition, a majority of PRN antihypertensives are IV medications and are associated with increased expenditures. For these reasons, it is vital to develop strategies that curb the routine prescription of PRN antihypertensives for adult inpatients. Current American Heart Association guidelines encourage clinicians to consider possible causes for blood pressure elevation and develop an individualized approach for management. In this pilot study, we utilized an implementation science framework with an aim to deprescribe PRN antihypertensives among hospitalized adult patients. Using a COM-B framework, we performed a barrier analysis followed by the development of an intervention bundle broadly consisting of education, environmental restructuring, and persuasion. Our results demonstrate a significant decrease in the percentage of patients receiving orders for PRN antihypertensives. In addition, we noted a reduction in the overall number of PRN antihypertensive orders, especially IV hydralazine. Despite a reduction in PRN antihypertensive orders, we noted a slight reduction in the number of infusions for hypertensive emergency management system-wide and no change in mortality among patients treated for hypertensive emergency. A significant advantage of our study is that our interventions did not involve any cost to the hospital medicine division or our health system and did not rely on extensive patient-level data collection. Therefore, we believe that these interventions can be easily adapted to various acute care facilities. In addition, our approach would allow possible refinement of interventions as needed based on outcome measures or available evidence regarding blood pressure management in the hospital. We believe that our study adds to existing knowledge regarding the management of hypertension in acute care settings in several important ways. First and foremost, this is the first study to successfully incorporate implementation science concepts to address PRN antihypertensive use in hospitals. Use of the COM-B framework to influence provider prescribing practices in hospital medicine is also novel. Implementation science has the potential to bridge the gap between rapidly evolving evidence and increasingly complex clinical practice. This study demonstrates the feasibility and ability of carefully selected implementation science concepts to attain meaningful outcomes in hypertension research. Second, the described interventions can be easily sustained and/or replicated owing to their favorable costs and easy reproducibility. This would allow comprehensive data collection and measurement of outcomes that will deepen our knowledge about hypertension management in the inpatient setting. Lastly, we believe that our study has demonstrated an effective and responsible approach to the use of widely available EHR data extraction tools that can be leveraged to design, monitor, and adapt interventions for appropriate hypertension management for hospitalized adults. Caution must be exercised in interpreting these results. Lack of randomized trial evidence on how to manage hypertension in the inpatient setting makes it challenging to offer specific guidance to providers. Despite careful messaging, the proposed interventions may create confusion among clinicians regarding the use of antihypertensives in appropriate clinical settings. In our study, we took care to reinforce the message that PRN antihypertensives should be minimized only in the treatment of asymptomatic HTN. EHR-generated reports may contain errors despite careful extraction and need to be interpreted cautiously. Lastly, it is unknown if provider behaviors will continue to respond to these interventions, have reached a plateau or revert to pre-intervention patterns. We plan to continue ongoing audits to analyze the longevity of these results and consider additional implementations such as a peer review of providers with ongoing high PRN use, sharing unblinded provider data with all hospitalist providers or refining provider education. Future studies will be needed to fully evaluate the reproducibility of our methods and results along with a thorough evaluation of potential harms caused by untreated asymptomatic hypertension in the hospital setting. Ultimately, randomized controlled trials will be needed to establish the best treatment strategies for elevated blood pressure in the inpatient setting. Data Availability Data used in this study will be made available to reviewers after removal of any individually identifiable information. References 1. ↵ Axon RN , Cousineau L , Egan BM . Prevalence and management of hypertension in the inpatient setting: a systematic review . J Hosp Med . 2011 Sep ; 6 ( 7 ): 417 – 22 . doi: 10.1002/jhm.804 . Epub 2010 Jul 22. PMID: 20652961 . OpenUrl CrossRef PubMed 2. ↵ Ghazi L , Li F , Chen X , Simonov M , Yamamoto Y , Biswas A , Hanna J , Shah T , Townsend R , Peixoto A , Wilson FP . Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment . J Clin Hypertens (Greenwich) . 2022 Mar ; 24 ( 3 ): 339 – 349 . doi: 10.1111/jch.14431 . Epub 2022 Feb 17. PMID: 35174627 ; PMCID: PMC8925013 . OpenUrl CrossRef PubMed 3. Herman LL , Bruss ZS , Tivakaran VS . Hydralazine . 2023 Mar 28. In: StatPearls [Internet] . Treasure Island (FL ): StatPearls Publishing ; 2024 Jan–. PMID: 29262006 . OpenUrl PubMed 4. Cawoski JR , DeBiasio KA , Donnachie SW , Timanus EA , Zimmerman DE , Guarascio AJ , Montepara CA , Covvey JR , Nemecek BD . Safety and efficacy of intravenous hydralazine and labetalol for the treatment of asymptomatic hypertension in hospitalised patients: A systematic review . Int J Clin Pract . 2021 Jul ; 75 ( 7 ): e13991 . doi: 10.1111/ijcp.13991 . Epub 2021 Jan 24. PMID: 33400322 . OpenUrl CrossRef PubMed 5. ↵ Miller JB , Hrabec D , Krishnamoorthy V , Kinni H , Brook RD . Evaluation and management of hypertensive emergency . BMJ . 2024 Jul 26; 386 : e077205 . doi: 10.1136/bmj-2023-077205 . PMID: 39059997 . OpenUrl Abstract / FREE Full Text 6. ↵ Bean-Thompson K , Exposito J , Fowler O , Mhaskar R , Chen L , Codolosa JN . Impact of Intravenous Antihypertensives on Outcomes Among Hospitalized Patients . Am J Hypertens . 2021 Aug 9; 34 ( 8 ): 867 – 873 . doi: 10.1093/ajh/hpab060 . PMID: 33864360 . OpenUrl CrossRef PubMed 7. Krouss M , Tsega S , Alaiev D , Talledo J , Chandra K , Manchego PA , Zaurova M , Shin D , Garcia M , Cho HJ . Reduction of Intravenous Antihypertensives through Clinical Decision Support in a Large Safety Net System . Jt Comm J Qual Patient Saf . 2023 Jun -Jul; 49 ( 6-7 ): 291 – 296 . doi: 10.1016/j.jcjq.2023.03.001 . Epub 2023 Mar 9. PMID: 37024423 . OpenUrl CrossRef PubMed 8. ↵ Lipari M , Moser LR , Petrovitch EA , Farber M , Flack JM . As-needed intravenous antihypertensive therapy and blood pressure control . J Hosp Med . 2016 Mar ; 11 ( 3 ): 193 – 8 . doi: 10.1002/jhm.2510 . Epub 2015 Nov 12. PMID: 26560085 . OpenUrl CrossRef PubMed 9. Salman J , Salman A , Kumar S , Gjeka R , Tegeltija V , Peterson D , Chams N , Ross I. Improving the use of intravenous antihypertensive medications in the hospital setting: a quality improvement initiative for patient safety . BMJ Open Qual . 2019 Nov 27; 8 ( 4 ): e000626 . doi: 10.1136/bmjoq-2019-000626 . PMID: 31803850 ; PMCID: PMC6887509 . OpenUrl Abstract / FREE Full Text 10. ↵ Gaynor MF , Wright GC , Vondracek S. Retrospective review of the use of as-needed hydralazine and labetalol for the treatment of acute hypertension in hospitalized medicine patients . Ther Adv Cardiovasc Dis . 2018 Jan ; 12 ( 1 ): 7 – 15 . doi: 10.1177/1753944717746613 . PMID: 29265003 ; PMCID: PMC5933643 . OpenUrl CrossRef PubMed 11. ↵ Jacobs ZG , Najafi N , Fang MC , Prasad PA , Abe-Jones Y , Auerbach AD , Patel S. Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative . J Hosp Med . 2019 Mar ; 14 ( 3 ): 144 – 150 . doi: 10.12788/jhm.3087 . PMID: 30811319 . OpenUrl CrossRef PubMed 12. ↵ Miller JB , Arter A , Wilson SS , Janke AT , Brody A , Reed BP , Levy PD . Appropriateness of Bolus Antihypertensive Therapy for Elevated Blood Pressure in the Emergency Department . West J Emerg Med . 2017 Aug ; 18 ( 5 ): 957 – 962 . doi: 10.5811/westjem.2017.5.33410 . Epub 2017 Jul 11. PMID: 28874950 ; PMCID: PMC5576634 . OpenUrl CrossRef PubMed 13. ↵ Bress , A. P. , Anderson , T. S. , Flack , J. M. , Ghazi , L. , Hall , M. E. , Laffer , C. L. , Still , C. H. , Taler , S. J. , Zachrison , K. S. , & Chang , T.I. ( 2024 ). The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association . Hypertension . doi: 10.1161/hyp.0000000000000238 OpenUrl CrossRef 14. ↵ Rastogi R , Sheehan MM , Hu B , Shaker V , Kojima L , Rothberg MB . Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions . JAMA Intern Med . 2021 Mar 1; 181 ( 3 ): 345 – 352 . doi: 10.1001/jamainternmed.2020.7501 . PMID: 33369614 ; PMCID: PMC7770615 . OpenUrl CrossRef PubMed 15. ↵ Muntner P , Shimbo D , Carey RM , Charleston JB , Gaillard T , Misra S , Myers MG , Ogedegbe G , Schwartz JE , Townsend RR , Urbina EM , Viera AJ , White WB , Wright JT Jr . Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association . Hypertension . 2019 May ; 73 ( 5 ): e35 – e66 . doi: 10.1161/HYP.0000000000000087 . PMID: 30827125 . OpenUrl CrossRef PubMed 16. Holland M , Lewis PS . An audit and suggested guidelines for in-patient blood pressure measurement . J Hypertens . 2014 Nov ; 32 ( 11 ): 2166 - 70 ; discussion 2170. doi: 10.1097/HJH.0000000000000306 . PMID: 25275246 . OpenUrl CrossRef PubMed 17. ↵ Kallioinen N , Hill A , Horswill MS , Ward HE , Watson MO . Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review . J Hypertens . 2017 Mar ; 35 ( 3 ): 421 – 441 . doi: 10.1097/HJH.0000000000001197 . PMID: 27977471 ; PMCID: PMC5278896 . OpenUrl CrossRef PubMed 18. ↵ Mohandas R , Chamarthi G , Bozorgmehri S , Carlson J , Ozrazgat-Baslanti T , Ruchi R , Shukla A , Kazory A , Bihorac A , Canales M , Segal MS . Pro Re Nata Antihypertensive Medications and Adverse Outcomes in Hospitalized Patients: A Propensity-Matched Cohort Study . Hypertension . 2021 Aug ; 78 ( 2 ): 516 – 524 . doi: 10.1161/HYPERTENSIONAHA.121.17279 . Epub 2021 Jun 21. PMID: 34148363 ; PMCID: PMC8266743 . OpenUrl CrossRef PubMed 19. Stewart B , Brody A , Krishnan AC , Brown SK , Levy PD . An Unmet Need Meets an Untapped Resource: Pharmacist-Led Pathways for Hypertension Management for Emergency Department Patients . Curr Hypertens Rep . 2019 Jun 19; 21 ( 8 ): 61 . doi: 10.1007/s11906-019-0965-4 . PMID: 31218526 . OpenUrl CrossRef PubMed 20. Giaimo AA , Kang AJ , Huot SJ . Hypertensive Urgency: An Emergency Department Pipeline to Primary Care Pilot Study . Am J Hypertens . 2021 Apr 2; 34 ( 3 ): 291 – 295 . doi: 10.1093/ajh/hpaa190 . PMID: 33216142 . OpenUrl CrossRef PubMed 21. Vitarello JA , Fitzgerald CJ , Cluett JL , Juraschek SP , Anderson TS . Prevalence of Medications That May Raise Blood Pressure Among Adults With Hypertension in the United States . JAMA Intern Med . 2022 Jan 1; 182 ( 1 ): 90 – 93 . doi: 10.1001/jamainternmed.2021.6819 . PMID: 34807229 ; PMCID: PMC8609458 . OpenUrl CrossRef PubMed 22. Anderson TS , Jing B , Fung K , Steinman MA . Older Adults’ Persistence to Antihypertensives Prescribed at Hospital Discharge: a Retrospective Cohort Study . J Gen Intern Med . 2021 Dec ; 36 ( 12 ): 3900 – 3902 . doi: 10.1007/s11606-020-06401-0 . Epub 2021 Jan 19. PMID: 33469765 ; PMCID: PMC8642581 . OpenUrl CrossRef PubMed 23. ↵ Wilson LM , Herzig SJ , Steinman MA , Schonberg MA , Cluett JL , Marcantonio ER , Anderson TS . Management of Inpatient Elevated Blood Pressures : A Systematic Review of Clinical Practice Guidelines . Ann Intern Med . 2024 Apr ; 177 ( 4 ): 497 – 506 . doi: 10.7326/M23-3251 . Epub 2024 Apr 2. PMID: 38560900 ; PMCID: PMC11103512 . OpenUrl CrossRef PubMed 24. ↵ Whelton PK , Carey RM , Aronow WS , Casey DE Jr . , Collins KJ , Dennison Himmelfarb C , DePalma SM , Gidding S , Jamerson KA , Jones DW , MacLaughlin EJ , Muntner P , Ovbiagele B , Smith SC Jr , Spencer CC , Stafford RS , Taler SJ , Thomas RJ , Williams KA Sr , Williamson JD , Wright JT Jr . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines . J Am Coll Cardiol . 2018 May 15; 71 ( 19 ): e127 – e248 . doi: 10.1016/j.jacc.2017.11.006 . Epub 2017 Nov 13. Erratum in: J Am Coll Cardiol. 2018 May 15;71(19):2275-2279. doi: 10.1016/j.jacc.2018.03.016. PMID: 29146535 . OpenUrl FREE Full Text 25. ↵ Mancia G , Kreutz R , Brunström M , Burnier M , Grassi G , Januszewicz A , Muiesan ML , Tsioufis K , Agabiti-Rosei E , Algharably EAE , Azizi M , Benetos A , Borghi C , Hitij JB , Cifkova R , Coca A , Cornelissen V , Cruickshank JK , Cunha PG , Danser AHJ , Pinho RM , Delles C , Dominiczak AF , Dorobantu M , Doumas M , Fernández-Alfonso MS , Halimi JM , Járai Z , Jelaković B , Jordan J , Kuznetsova T , Laurent S , Lovic D , Lurbe E , Mahfoud F , Manolis A , Miglinas M , Narkiewicz K , Niiranen T , Palatini P , Parati G , Pathak A , Persu A , Polonia J , Redon J , Sarafidis P , Schmieder R , Spronck B , Stabouli S , Stergiou G , Taddei S , Thomopoulos C , Tomaszewski M , Van de Borne P , Wanner C , Weber T , Williams B , Zhang ZY , Kjeldsen SE . 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA) . J Hypertens . 2023 Dec 1; 41 ( 12 ): 1874 – 2071 . doi: 10.1097/HJH.0000000000003480 . Epub 2023 Sep 26. Erratum in: J Hypertens. 2024 Jan 1;42(1):194. doi: 10.1097/HJH.0000000000003621. PMID: 37345492 . OpenUrl CrossRef PubMed 26. Michie S , van Stralen MM , West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions . Implement Sci . 2011 Apr 23; 6 : 42 . doi: 10.1186/1748-5908-6-42 . PMID: 21513547 ; PMCID: PMC3096582 . OpenUrl CrossRef PubMed 27. ↵ Mather M , Pettigrew LM , Navaratnam S. Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel . Syst Rev . 2022 Aug 30; 11 ( 1 ): 180 . doi: 10.1186/s13643-022-02030-2 . PMID: 36042457 ; PMCID: PMC9429279 . OpenUrl CrossRef PubMed 28. ↵ Canales MT , Yang S , Westanmo A , Wang X , Hadley D , Ishani A , Mohandas R , Shorr R , Lo-Ciganic W. As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals . JAMA Intern Med . 2025 Jan 1; 185 ( 1 ): 52 – 60 . doi: 10.1001/jamainternmed.2024.6213 . PMID: 39585709 ; PMCID: PMC11589853 . OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted August 21, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Deprescribing Pro Re Nata Antihypertensives in the Hospital An Implementation Science Pilot Study Based on the COM-B Framework Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. 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