Fixed-Dose Combinations for Hypertension: Barriers to Use and Opportunities for Health Systems.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Clin Hypertens (Greenwich) . 2026 Jun 2;28(6):e70300. doi: 10.1111/jch.70300 Fixed‐Dose Combinations for Hypertension: Barriers to Use and Opportunities for Health Systems Pranay Narang 1, 2, ✉ , Josselyne Marquez 3 , Neema Rashidi 1 , Rohini Haar 3 , Sandeep P Kishore 4 Author information Article notes Copyright and License information 1 University of California, Berkeley, University of California, San Francisco Joint Medical Program, Berkeley, California, USA 2 Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA 3 School of Public Health, University of California, Berkeley, Berkeley, California, USA 4 Department of Medicine, University of California, San Francisco, San Francisco, California, USA ✉ Corresponding author. Revised 2026 Apr 27; Received 2026 Jan 15; Accepted 2026 May 13; Collection date 2026 Jun. © 2026 The Author(s). The Journal of Clinical Hypertension published by Wiley Periodicals LLC. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. PMC Copyright notice PMCID: PMC13238747  PMID: 42227201 ABSTRACT Background : Uncontrolled hypertension is a leading driver of heart disease, chronic kidney disease, heart failure, dementia, stroke, and pregnancy‐related complications. Fixed‐dose combinations (FDCs) are guideline‐endorsed first‐line therapies that improve blood pressure control by reducing pill burden, improving adherence, and targeting multiple pathophysiological mechanisms. However, FDC utilization remains low across U.S. health systems. Few studies examine the factors influencing FDC uptake; existing qualitative studies rarely interrogate structural barriers or formulate stakeholder‐informed recommendations. Methods : We explored the perspectives of providers, population health stakeholders, and health system executives through semi‐structured interviews/thematic analysis to identify structural and provider‐level barriers to FDC utilization and formulate recommendations for health systems. Results : Structural barriers included low exposure to FDCs early in training, entrenched monotherapy‐reliant cultures, workflow constraints, fragmented formularies, and absent performance incentives and leadership endorsements. Provider‐level perspectives and practices diverged: clinicians reported minimal use of FDCs, limited familiarity with FDCs, and concerns about dosage inflexibility and adverse effects. By contrast, pharmacists and nurse practitioners identified as major proponents of FDCs, demonstrated broad familiarity with therapeutic and cost advantages, and reframed clinicians concerns as misconceptions due to limited exposure. Conclusions : To improve FDC utilization, we propose: (1) integrating FDC exposure into early medical and pharmacy curricula; (2) embedding decision‐support tools and SmartSets that prompt FDC consideration into electronic medical records; (3) expanding team‐based care models to distribute responsibility for medication intensification; (4) securing leadership endorsements, novel incentive structures for providers, and data tracking mechanisms; and (5) fostering normative change through champions, CME‐accredited workshops, and socialization strategies. Keywords: chronic disease, fixed‐dose combinations, hypertension, qualitative research 1. Introduction Uncontrolled hypertension is a global epidemic and a major public health crisis. It is a leading risk factor for ischemic heart disease, chronic kidney disease, dementia, stroke, heart failure, and pregnancy‐related complications; and a significant driver of healthcare costs in the United States (U.S.) [ 1 ]. As of 2024, nearly half of all U.S. adults (48.1%, ∼119.9 million) have stage 1 hypertension (≥130/80 mmHg), and approximately 37 million have stage 2 hypertension (≥140/90 mmHg [ 2 , 3 ]. Globally, over 1.28 billion people are hypertensive, two‐thirds of whom reside in low‐or‐middle‐income countries (LMICs) [ 4 ]. The health, social, and economic burdens of living with hypertension are profound, including increased disability, impaired work capacity, and the long‐term costs of ongoing medical care, and disproportionately affect Black and Hispanic communities. Only about one in two U.S. adults diagnosed with hypertension achieve BP control under the traditional <140/90 mmHg threshold. When applying the updated Centers for Disease Control and Prevention (CDC) standard (<130/80 mmHg), the proportion falls to just 20.7% [ 5 , 6 , 7 , 8 ]. The central challenge is not a lack of treatment options—given the availability of accurate BP measurement techniques and effective antihypertensive therapies – but the multifactorial barriers that prevent effective and sustained BP control. As identified by the American Heart Association and American Medical Association, these barriers span across structural, patient, and clinician‐levels [ 9 ]. Structural barriers include variable BP treatment protocols, fragmented care coordination, limited access to care, and the broader impacts of social determinants of health such as poverty and institutional racism [ 9 ]. Patient‐level barriers include poor medication adherence, limited health literacy, misconceptions about hypertension, depression, cognitive decline, comorbidities, and inadequate social support. Among these, addressing nonadherence is crucial, with up to 16–50% of patients discontinuing antihypertensive therapy within the first year [ 10 ]. Clinician‐level barriers include suboptimal communication, lack of familiarity or confidence in guidelines, and clinical inertia, defined as the failure to initiate or intensify therapy when indicated [ 7 , 11 , 12 , 13 ]. This often stems from competing clinical priorities, uncertainty about BP measurements, inadequate training on achieving BP targets, and overestimation of quality of care provided [ 9 , 10 ]. These barriers underscore the pressing need for strategies that simplify treatment, promote adherence, and overcome clinical inertia [ 14 ]. Early use of fixed‐dose combinations (FDCs), also known as single‐pill combinations, which combine two or more antihypertensive agents from different classes, is one such strategy that has been shown to improve BP control and adherence by reducing pill burden and targeting multiple pathophysiologic mechanisms contributing to hypertension simultaneously [ 15 , 16 , 17 , 18 ]. This approach is supported by evidence that at least 75% of patients will require more than one agent to achieve BP targets [ 19 , 20 , 21 , 22 , 23 ]. One systematic review of 14 randomized controlled trials (5120 participants) demonstrated that FDCs improved BP control by 27% (95% CI 15–41%) compared to monotherapy without increasing treatment discontinuation [ 21 ]. Improving BP control rates by 25% at scale would bring an additional 80 million people to their BP goal and avert hundreds of thousands of fatal or disabling cardiovascular events annually [ 21 ]. Accordingly, the World Health Organization, American College of Cardiology (ACC), and European Society of Cardiology now recommend initiating treatment with at least two agents – preferably as an FDC – for patients with markedly elevated BP [ 7 , 24 , 25 ], with the most recent American Heart Association(AHA)/ACC guidelines specifically advising FDC initiation for patients with BP >140/90 mmHg [ 26 ]. Despite guideline‐directed medical therapy (GDMT) endorsements, compelling evidence, and the wide availability of combinations – including ACE Inhibitors (ACEI), Angiotensin Receptor Blockers (ARBs), dihydropyridine calcium‐channel blockers (CCBs), and diuretics, virtually all (excluding ACEI/ARB pairings) of which show consistent BP‐lowering efficacy and cardiovascular protection [ 27 ], FDC utilization remains strikingly low. Most U.S. patients are managed with monotherapy or dual therapy using separate agents. Only 10–15% of prescriptions for patients with uncontrolled hypertension are written as FDCs, reflecting a gap between GDMT and practice [ 7 , 21 , 28 , 29 , 30 ]. At the University of California Health (UCH), comprising six academic health centers serving 9.5 million outpatient visits annually [ 31 ], similar trends persist: in a hypertension cohort of 100,000, only 6.8% of patients prescribed FDCs as of October 2023 (UCH Internal Analytics). To address this gap, UCH developed and disseminated the UC Way Hypertension Medication Algorithm, a standardized, evidence‐based medication algorithm adopted across all UC sites. The algorithm features FDCs as the first‐line therapeutic option and is designed to guide medication intensification, reduce clinical inertia, and promote timely achievement of BP targets. Despite these efforts, system‐wide adoption of FDCs remains low. Few studies examine the complex factors influencing FDC utilization. Existing qualitative work rarely interrogates structural barriers or offers stakeholder‐informed recommendations, focusing primarily on provider or caregiver views [ 32 , 33 ]. These evidence gaps highlight a pressing need for qualitative inquiry that captures the nuanced, multilevel barriers to adoption. This investigation aims to address these gaps by exploring the perspectives and experiences of clinicians, pharmacists, population health stakeholders, and health system executives around FDCs to identify barriers to FDC utilization and generate actionable recommendations. Through semi‐structured interviews, we sought to capture the explicit needs of clinicians, pharmacists, population health stakeholders, and institutional leaders to comfortably prescribe and endorse FDCs, while delineating structural, systemic, and individual considerations that limit FDC uptake. In doing so, we aim to inform system‐wide interventions that promote FDC adoption, improve BP control across diverse populations, and advance health equity. 2. Methods 2.1. Study Design and Recruitment Strategy A qualitative methodology using one‐on‐one, semi‐structured interviews was employed to explore participants’ perspectives, experiences, and recommendations regarding FDC utilization. We employed reflexive thematic analysis, incorporating deductive and inductive approaches, to identify recurring themes from the data [ 34 , 35 ]. Interviews were conducted from November 2024 to April 2025 with clinicians across specialties – including internal medicine, family medicine, cardiology, endocrinology, and emergency medicine – as well as pharmacists, nurse practitioners (NPs), social workers, population health leaders, and health systems executives to understand a broad spectrum of perspectives (Table 2 ). Purposive and snowball sampling was employed to deliberately recruit individuals directly involved in hypertension care or engaged in hypertension‐related population health initiatives. Recruitment was limited to institutions within the UCH system – where FDC utilization remains low (6.8%) – and a regional, vertically integrated health system with higher uptake, to enable comparative analysis. We prioritized outpatient settings, where hypertension is commonly diagnosed, managed longitudinally, and reliably documented, rather than inpatient settings, where hypertension treatment is frequently episodic or secondary to acute illness. TABLE 2. Characteristics of study participants ( n = 23). Characteristic Value a Mean age (range) 47.9 (28–71) Female participants 15 (65.2%) Mean years in practice (range) 17 (2.5–35) Primary practice setting, n (%) Outpatient 16 (69.6) Inpatient 7 (30.4%) Clinical role/specialty training, n (%) Clinicians 14 (60.9%) Internal medicine 6 (26.1%) Family medicine 2 (8.7%) Cardiology 2 (8.7%) Endocrinology 1 (4.3%) Emergency medicine 3 (13%) Clinical pharmacists 6 (26.1%) Nurse practitioners 2 (8.7%) Social workers 1 (4.3%) Hypertension‐related experience, n (%) Eligible to prescribe antihypertensive agents 22 (95.6%) Engaged in population health initiatives for hypertension 13 (56.5%) Population health leadership 8 (34.8%) Health systems executives 2 (8.7%) Institution type, n (%) UC Health‐Affiliated 20 (87%) Vertically Integrated Health System Affiliated with High FDC Uptake 3 (13%) Past Training or Practice in Vertically Integrated System with High FDC Uptake 5 (21.7%) Open in a new tab Abbreviation: FDC, fixed‐dose combination. a Data are expressed as number (%), unless noted. Thirty‐five professionals were contacted via email, of whom twenty‐three agreed to participate. Of these, twenty‐one interviews were conducted virtually and two in‐person, each lasting 30 to 65 min. 2.2. Data Collection For data collection, a semi‐structured interview guide was developed and iteratively refined based on input from faculty experts in hypertension and qualitative research (SPK, RH) (Appendix A ) [ 19 , 21 , 36 , 37 , 38 , 39 , 40 ]. Questions were informed from a literature review on barriers to achieving BP control, overarching objectives (Table 1 ), and the authors’ conceptual framework on barriers to FDC utilization. A draft guide was piloted with two stakeholders, and feedback informed refinements to improve clarity and relevance in addressing the study's aims. Interviews focused on three a priori domains – (1) structural barriers to FDC prescribing, (2) provider‐level perspectives, experiences, and barriers; and (3) recommendations for improving FDC uptake. TABLE 1. Outline of overarching objectives and corresponding guiding questions for interviews. Objectives Sample of semi‐structured interview questions (Appendix A ) Identify clinician, pharmacist, and nurse practitioner‐level considerations, factors, experiences, and concerns influencing FDC prescribing. Have you heard about Fixed‐Dose Combinations (FDCs) as a tool to achieve BP control when treating patients for hypertension? How often would you say you make adjustments to patients’ medication regimens to include FDCs in a given week? What patient populations do you consider appropriate for prescribing FDCs? When prescribing two separate monotherapies instead of an FDC, could you describe some of the reasoning behind that decision? When considering FDCs, do you worry about managing adverse effects? Have you seen any adverse effects after prescribing FDCs to patients? When considering prescribing FDCs, do you worry about costs? Do you know which insurers cover FDCs and which do not? Or the extent to which FDCs may be covered? Identify the structural barriers and facilitators influencing FDC utilization within open and integrated health systems. Where did you learn about FDCs? Do you feel your medical training and education adequately prepared you to consider utilizing FDCs as a dual therapy for hypertension? Do your colleagues use FDCs? Why or why not? If your colleagues prefer other therapeutic agents, why might that be? Are you aware of any existing EHR‐based alert or tool that may prompt you to consider FDCs? Have you heard about the UC Way Hypertension Medication Algorithm? Identify patient‐level considerations, factors, experiences, and concerns influencing FDC uptake. Can you describe some concerns that patients have expressed to you about FDCs? Have patients expressed concern about costs? What about adverse effects? What about intensifying medication too quickly? Are patients generally receptive or reluctant to utilize FDCs when you prescribe it? Elicit systemwide recommendations by stakeholders (e.g., clinicians, pharmacists, population health stakeholders, health system executives) to promote FDC utilization. What do you think could be incorporated into your clinical workflow – the setting that you work or the rhythm of your day or your institution more broadly – to promote the utilization of FDCs? Open in a new tab Data collection was concluded once thematic saturation was reached, defined as the point when subsequent interviews yielded no substantial new concepts. This determination was made in consultation with study team members experienced in qualitative research, with consideration of relevant literature (RH, NR) [ 41 ]. All interviews were audio and video‐recorded via Zoom v6.1.10 (Zoom Video Communications Inc.), transcribed via Sonix (Sonix, San Francisco, CA), reviewed and verified for accuracy, and anonymized with unique deidentified labels by the study team, following which recordings were permanently deleted in consideration of expert guidance [ 42 ]. Anonymized transcripts were stored on secure folders and uploaded to Dedoose (Dedoose, Manhattan Beach, CA) for coding and analysis. This study was approved by the Institutional Review Boards of the University of California, Berkeley and the University of California, San Francisco. 2.3. Qualitative Analysis The analytic process proceeded through three stages: (1) initial deductive coding using a priori codes; (2) inductive development of new codes, themes, and subthemes that expanded and further categorized the a priori domains; and (3) comparative analysis of thematic patterns and differences across stakeholders. To ensure reliability and consistency, two coders (PN, JM) were trained on an initial set of a priori codes and practiced independently coding two interviews under the guidance of experienced qualitative researchers (RH, NR). This process enabled resolution of early discrepancies and calibration of a preliminary, aligned coding approach. Thereafter, following the framework laid out by Kiger et al. [ 43 ], PN and JM independently reviewed and coded each transcript, meeting to discuss emerging concepts and inductively refine the codebook to jointly formalize categories, subcategories, and interrelated themes and subthemes [ 34 ]. Following coding, comparative analysis was conducted systematically. PN manually reviewed all excerpts and organized each quotation into corresponding themes and subthemes in a master analytic spreadsheet. This chart served as the foundation for data synthesis and was subsequently distilled into Tables 3 and S1A–C) after consensus was reached on thematic results with the study team. Reflexivity – the process of critically examining and acknowledging how the study team's perspectives, experiences, assumptions, and positionalities may have influenced the research process, was prioritized throughout data collection, coding, and synthesis [ 44 ]. This study was conducted in accordance with COREQ guidelines [ 45 ]. TABLE 3. Recommendations for health system leaders to promote FDC utilization. Recommendations Strategies and solutions Exemplary quotes Incorporate FDCs early into medical and pharmacy training Embedding FDCs in curricula around hypertension in medical and pharmacy school, and emphasizing the importance of medication intensification for patients with hypertension. “Just yesterday, we had a meeting and I was really impressed [to learn] about FDCs in [one medical school's] curriculum. They're starting before providers even become prescribers. That's a novel idea. Right now, we're trying to change practices that are already deeply ingrained – people who've been trained on monotherapy and don't want to change. But if we start early, we can change prescribing habits before they're set. I've been talking to a pharmacy colleague, and I'd like to explore whether we can do this in our medical, nursing, and pharmacy schools too.” (Clinical Pharmacist) “[One medical school] is going to be teaching this to their students—medical students and residents—so they learn about fixed‐dose combinations and their benefits before they start practicing. I think that's a great strategy. It's hard to teach an old dog new tricks so starting while everything's still fresh just makes sense.” (Clinical Pharmacist) Electronic Medical Record Integration Integrate FDCs into decision‐support tools and SmartSets “The more you can provide doctors with decision support tools, the better. When you're busy and have to make ten different decisions for a single treatment, having something that simplifies the process is really helpful. Sometimes I just need a refresher or quick guidance for a disease—an algorithm that says, ‘Where's my patient? Step one—do this.’ That's something Kaiser does really well.” (Clinical Pharmacist) “It's different from a guideline. A guideline might be 15–30 pages long—a comprehensive literature review, often vague. A decision support tool, on the other hand, distills that into a one‐ or two‐pager—or a digital version—that reflects your specific health system, formulary, and patient population. You can enter patient info on your phone, and boom—it tells you what to do. Without that, if you're busy and uncertain at any step, you're likely to just default and prescribe something familiar.” (Clinical Pharmacist) “When ordering, you have to know that you're looking for an FDC. There's not an alert or prompt that says, ‘consider a single‐dose combination for this patient.’ That would help. Right now, you have to be intentional—and know what's in the combination. An alert or guide would be useful if, when a clinician types in a monotherapy, it suggests a fixed‐dose combination—or flags that a patient on two components might be eligible for a combo.” (Clinical Pharmacist) “Say I type in amlodipine—what if combinations that include amlodipine popped up? That would help providers ask themselves, ‘Should I start a fixed‐dose combo instead?’” (Clinical Pharmacist) "I also think, like, you know, clinical decision support tools can be helpful—because to some extent, part of clinical inertia might just be that somebody's like, ‘Oh… what med do I do next?’ Not that it's necessarily complicated, but it's that extra cognitive burden. And if there's a decision support tool that's designed with people's feedback in mind and feels customized for the health system—like, it's not generic—it can really help. If it just says something like, ‘Hey, this patient has a blood pressure greater than X, and they're already on these meds—here's what we suggest next,’ that's super useful.” (Internal Medicine‐trained Primary Care Provider) "We [need] a Smart Set for hypertension. It would include FDCs across drug classes, prioritize those covered by insurance, and reduce the burden of figuring it out from a long list. You can select what you need and sign it all at once.” (Family Medicine Physician) Invest in team‐based care models for hypertension that integrate pharmacists, medical assistants, and nurses into hypertension workflows for medication titration and follow‐up care. Delegate responsibility for medication intensification – including through FDCs or dual single agents – to multiple members of the care team. “Partnership with nurses and pharmacists—making sure they're also familiar with FDCs and comfortable titrating them—is essential. Even if the physician starts the prescription, follow‐up often happens with nurses or pharmacists, so they need to know how to ramp it up.” (Internal Medicine‐trained Primary Care Provider) “Honestly, I think you need to take it out of the PCP's hands. Nurses and pharmacists are better at following guidelines and saying, ‘This patient is above target—let's increase meds.’ PCPs are distracted. Sometimes they think, ‘This doesn't apply to my patient,’ or feel they don't need to follow every guideline. Shifting hypertension management to others can really help.” (Internal Medicine‐trained Primary Care Provider) “I think having more support staff to follow up with patients would be a good idea. At [one institution], for example, in addition to the clinical pharmacist, we have medical assistants who hold their own appointments just to do blood pressure follow‐up. There's a guideline in place—if a patient comes in with high blood pressure for any reason, the MA will automatically schedule a follow‐up within two weeks to a month. That visit can be in person or over the phone, if the patient has a cuff at home. I think that kind of routine follow‐up has helped improve blood pressure outcomes—even aside from whether or not the patient is on an FDC.” (Internal Medicine Resident) Strengthen Top‐Down Support and Accountability for FDC Utilization Secure leadership endorsements to normalize FDC use “Like most things, you'd have to get the leaders of these clinical groups to endorse it. If it was very clear this is a better way to treat blood pressure, then we could say: to optimize your blood pressure control statistics, this would be rational.” (Provider and Health System Executive) Establish incentive structures that promote FDC utilization among providers “We have a PCP incentive plan. It's part of their bonus structure. But there's no incentive around how the blood pressure is controlled. Some patients don't need drugs—others do. So we're not incentivizing a particular strategy.” (Provider and Health System Executive) Track FDC utilization using key performance indicators (KPIs) “The first thing is just to go into the weeds and figure out who's already on both a diuretic and [another agent]—on two pills that are available as one. That's low‐hanging fruit. Then you just reach out and say, your patient is on these two pills; this exists as a fixed combination. Would you consider changing it over?” (Cardiologist) “Especially at the site or clinic level, we've seen this kind of approach work for other interventions. It's about really drilling down into a particular practice and identifying where performance is trending in the right direction—where there might actually be significant improvement. And then asking: is it something specific to that department or clinic? Is it something about the way a certain group of physicians is operating? That's where a population health or quality improvement team can come in—work with the clinicians and really dig into what's working. Is it an education piece? A workflow piece? Or maybe it's a combination of factors, including some type of technology or decision‐support tool. That's the improvement science approach: using data to guide where you invest your time, figuring out what's working well, and then taking that learning and seeing what you can spread to other clinics or practices across the system.” (Nurse Practitioner) “We [currently] track use of confirmatory blood pressures—patients come in with a high BP, they wait, we recheck it. That's a process measure. But we're also developing KPIs around fixed‐dose combination use… how many patients with hypertension are on no medication, one agent, two or more agents, or two agents in a single pill.” (Nurse Practitioner) “Providing data and feedback on what percentage of our patients are on FDCs in practice – that's essential.” (Internal Medicine‐trained Primary Care Provider) “Use of FDCs is one way to gauge how aggressively people are managing blood pressure—or how up to date they are. Why not look directly at BP control rates and what meds people are actually using?” (Internal Medicine‐trained Primary Care Provider) Foster a normative shift through education and socialization initiatives. Appoint FDC “champions” across clinical sites who facilitate FDC check‐ins during provider meetings. “We're asking providers to make a big behavioral shift, and they probably need more than an email or handout. What's effective – though not true for everyone – is hearing from a trusted peer. In our case, a physician and a clinical pharmacist were both involved. That gave two different voices and perspectives. Having an MD talk to other MDs – sharing literature and personal stories – adds legitimacy.” (Clinical Pharmacist) “This should be a recurring check‐in at provider meetings – ask who's started using FDCs, share experiences. Peer‐to‐peer interactions are powerful. If a colleague's patient did well on an FDC, I'm more likely to try it too, especially if it saves the patient a pill.” (Clinical Pharmacist) Offer educational sessions with CME credit “Educational sessions should really make the case for why FDCs offer numerous advantages in clinical practice and for controlling blood pressure. We did that through group presentations with residents, trainees, and experienced primary care physicians—presented the evidence, heard their feedback, addressed concerns, and shared a detailed FAQ. Education and training are key.” (Internal Medicine‐trained Primary Care Provider) “Show the evidence – why they're effective and which combinations are best supported. But also offer practical guidance tailored to our safety‐net setting. For example, highlight strong data on CCB/ARB combinations, like from the ACCOMPLISH trial, and explain which FDCs are covered and how to initiate them.” (Internal Medicine‐trained Primary Care Provider) “If you really want a doctor to pay attention, make it a CME. Even if they're not initially interested in the topic, they might attend because it counts toward license renewal. We considered creating a CME but thought, ‘No one needs to learn about hypertension – this is basic, they won't come.’ But a few UC sites – UCSF, UC Riverside, and later UC Davis – ended up doing it anyway as part of an educational discussion. And we decided to move forward with it too.” (Clinical Pharmacist) “You can incentivize learning through CME credit. A lot of people go to grand rounds for the CME—not just the content.” (Provider and Health System Executive) Leverage tools from the UC Hypertension Medication Workgroup (e.g. The UC Way Hypertension Algorithm) for education and socialization efforts “We developed an overview deck with an image of the algorithm, a clinical infographic, and some background on why the group was created. There's also a standalone infographic, which is essentially a roadmap: you take a patient's blood pressure, see that it's high, apply the algorithm, and titrate medications when appropriate. We also made an email template that providers could send to a department listserv – like Internal Medicine – to socialize the algorithm.” (Population Health Stakeholder) “We had a pharmacist come to a professional development session to introduce the algorithm. They presented it as a set of options, emphasized insurance coverage, and reassured us it was easy to use. I've accepted it more. And while I haven't reviewed charts, I haven't heard any pushback [from colleagues]. The pharmacist team presented the algorithm, and then our medical director sent it out again afterward. That kind of reinforcement helps make it stick.” (Nurse Practitioner) Use messaging that acknowledges and addresses providers' perceived risks of dosage inflexibility and adverse effects when using FDCs “There's a lot of fear around monitoring two medications in one, but we do the same when patients are on multiple antihypertensives.” (Clinical Pharmacist) “You'd probably have to say, like, ‘Oh, I get it. I was hesitant too – for the same reasons you're explaining. But there's newer evidence that supports it." (Clinical Pharmacist) “I think analogies to other medications – like Entresto for heart failure – could help. That's a fixed‐dose combination that people are familiar with and trust, so using that as a comparison might make it easier for providers to understand FDCs for hypertension.” (Internal Medicine Physician) Open in a new tab 3. Results A total of 23 participants were interviewed, including fourteen clinicians (six internal medicine, two family medicine, two cardiology, one endocrinology, three emergency medicine), five clinical pharmacists, two nurse practitioners; and one social worker (Table 2 ). All participants had direct experience treating or managing patients with hypertension, and over half were actively engaged in population health activities related to hypertension, such as research, quality improvement, or systems‐based care delivery. Participants offered insight into clinical, organizational, and structural barriers to FDCs adoption. Interviews lasted between 30 and 65 min. Findings are organized across the three a priori domains – (1) structural barriers to FDC prescribing, (2) provider‐level perspectives, experiences, and barriers to FDC utilization; and (3) recommendations for health system leaders to promote FDC uptake. Within each domain, we identify themes and subthemes with exemplary quotes directly from the interviews. To enhance rigor and transparency and synthesize findings concisely, we include additional exemplary quotations in Tables S1A–C . During analysis, the research team interpreted participants’ use of the term “integrated systems” to refer to care models in which insurance, hospitals, clinics, and providers operate under a single organizational structure. In contrast, the term “open systems” referred to decentralized care models in which hospitals, clinics, and providers operate independently of insurers. “Stepwise monotherapy” refers to the clinical practice of initiating hypertension treatment with a single antihypertensive agent, gradually titrating the dosage, and adding additional medications – typically as single agents – only if blood pressure targets are not achieved. 3.1. Structural Barriers to FDC Utilization Participants identified systemwide barriers to FDC utilization, including limited exposure in training, entrenched cultural norms around stepwise monotherapy, constrained clinical workflows, variability in health system design, and absent leadership endorsements or systemwide incentives (Table S1A ). 3.1.1. Limited Training Exposure Contributes to Low FDC Use All participants reported receiving limited exposure to FDCs during their education and training. Instruction reportedly emphasized a stepwise monotherapy‐based approach: starting with a single agent, titrating gradually, and incorporating a second agent if BP remained uncontrolled. Several clinicians first encountered FDCs only after completing residency, often through patient medication lists rather than formal instruction. This late exposure contributed to variable familiarity and comfort with FDCs across providers, as well as limited recognition of therapeutic advantages. As one participant noted: “I definitely know [FDCs] weren't something that we emphasized starting patients on when I was in residency. I don't know if I was exposed at all.” (Internal Medicine‐trained Primary Care Provider) 3.1.2. Lack of Cultural Reinforcement Limits FDC Uptake Despite being underemphasized in training, pharmacists and NPs described workplace cultures that increasingly recognized the therapeutic value of FDCs and supported their use. Shared prescribing norms and peer reinforcement contributed to broader FDC uptake. “As pharmacists, we really try our best to use FDCs. I took over for another pharmacist and most of her patients were on some sort of FDC. We try to use them because patients are already on so many medications.” (Clinical Pharmacist) In contrast, clinicians consistently reported that FDCs were rarely part of their practice cultures. FDCs were seldom discussed among colleagues, considered in workflows, addressed in professional conferences, or modeled by specialists. As one clinician observed: “I don't see cardiologists using them either, even though many of us tend to model our hypertension management after what we see from nephrologists and cardiologists. I haven't seen any patients followed by them who are on FDCs.” (Family Medicine Physician) 3.1.3. Clinical Workflow Constraints Impede Consideration of FDCs Primary care providers (PCPs) highlighted that the realities of clinical practice limit their ability to consider or prioritize FDCs. Competing clinical and social concerns, such as housing insecurity, frequently take precedence over timely medication intensification. Time constraints further reinforce reliance on more familiar single agents over FDCs. As one pharmacist observed: “[PCPs] don't have time to look up [FDCs] at the moment. The patient's right in front of them, and they've got seven more to see. So, no one's going to pause and go research it.” (Clinical Pharmacist) 3.1.4. Health System Design Variability Limits Standardized FDC Adoption Health system design markedly shaped FDC utilization. Participants with experience in a vertically integrated health system highlighted that standardized formularies, strong leadership endorsements, and team‐based care models – where non‐physician providers often lead medication intensification – enabled routine FDC use. One health system executive noted: “[Integrated systems] have been promoting dual therapy as the initial hypertension treatment strategy for a long time. When I worked there, that's when I first became aware of it, learned about it, and started using it.” (Provider and Health System Executive) By contrast, clinicians practicing in open, academic systems described fragmented environments less conducive to aligned prescribing practices. Variable formularies, inconsistent insurance coverage, and lack of centralized governance limited clinicians’ visibility into which FDCs were accessible. Institutional cultures further reinforced individualized, clinician‐driven decision‐making over standardized guideline adherence. Still, some participants recognized opportunities within these challenges. One executive argued that open systems, given their scale, visibility, and academic influence, were uniquely positioned could set a national example for hypertension management if they embraced FDC adoption: “ Maybe [open systems are] the best place – because if you can do it there, you can show the world how to [manage hypertension] in an academic setting. Being an academic center is a double‐edged sword.” (Provider and Health System Executive) 3.1.5. Absence of Leadership Endorsements and Incentives Limits FDC Use Participants engaged in population health initiatives described past efforts to promote FDC utilization, such as the development and implementation of The UC Way Hypertension Medication Algorithm in 2023. Yet without stronger leadership endorsements, both algorithm and FDC adoption remained limited. They also noted that while performance incentives exist for other conditions – for example, aligning heart failure treatment with five major medication classes – comparable expectations for hypertension strategies like FDC were absent: “There's no incentive – monetary or otherwise – for clinicians to prescribe FDCs, and no repercussions if they don't….It's really all volunteerism. What's happening is that a group of motivated individuals have [developed this algorithm] because they believe in [FDCs]. They've decided this is important and are choosing to focus on it clinically and spread it among their peers.” (Population Health Stakeholder) 3.2. Provider‐Level Perspectives Influencing FDC Utilization While structural barriers shaped the broader context for FDC utilization, clinicians’ varying knowledge, treatment preferences, and concerns emerged as prominent barriers to FDC use (Table S1B ). 3.2.1. Clinicians’ Awareness, Familiarity, and Knowledge of FDCs Varies Clinicians across specialties demonstrated wide variability in their understanding of FDCs. For instance, all emergency medicine physicians were unaware of FDCs as a therapeutic option for hypertension: “ You mean two meds in one pill? I don't think I've heard of that.” (Emergency Medicine Physician) “FDCs? What is that?” (Emergency Medicine Physician) “We don't really think about those.” (Emergency Medicine Physician) Even among internal medicine‐trained, family medicine‐trained, and cardiology‐trained clinicians, several participants reported limited familiarity or confidence in FDCs’ therapeutic value and expressed rarely using them in practice. As one cardiologist emphasized, “We don't prescribe them. The main reason is because when we're seeing our patients, we're titrating medication to get them to a certain goal. So, it's harder to do that when you have dual treatments.” (Cardiologist) Uncertainty about FDC formulary coverage and affordability further discouraged use. Nearly all clinicians noted little visibility into what was available or affordable at their practice sites. “That's a jungle that I have no overview over.” (Internal Medicine‐trained Primary Care Provider) “I don't even know if those are covered by insurance or things like that.” (Cardiologist) These knowledge gaps reflected limited awareness of FDCs' potential to reduce patient copays and improve adherence. 3.2.2. Clinicians Have Ingrained Monotherapy‐Reliant Prescribing Habits Furthermore, clinicians reported greater comfort with longstanding prescribing habits, formed during residency training and reinforced in practice, that favor stepwise monotherapy. These habits persist even as guidelines increasingly support early combination therapy, especially for patients with moderate or severe hypertension [ 19 , 20 , 21 , 22 ]. One clinician noted: “I don't know if I ever initiated a fixed dose regimen. I will usually do a single agent first. So, I would say pretty pretty rarely.” (Internal Medicine Physician) These preferences revealed inconsistent recognition of evolving evidence and reluctance to shift from monotherapy‐first approaches. 3.2.3. Clinicians Hesitate to Prescribe FDCs Due to Perceived Risks of Dosage Inflexibility, Side Effects, and Patient Confusion Among clinicians aware of FDCs but hesitant to use them, the most common concern was the perceived lack of dosage flexibility. Participants reported that they could not titrate one drug component without affecting the other, hindering side effect management. As one participant described: “With a fixed‐dose combination, I can't adjust one med without affecting the other – I can't pull them apart. That's tricky when you're managing side effects. Thiazides can cause orthostatic hypotension, ACE inhibitors can cause electrolyte disturbances or cough, and calcium channel blockers can lead to edema. You want to maximize blood pressure control while minimizing side effects, but FDCs limit your ability to titrate each component independently.” (Internal Medicine Physician) Other clinicians noted that they would not be able to identify which agent was responsible for adverse effects, despite the distinct side effect profiles of common agents and evidence that FDCs are designed with synergistic agents that attenuate side effects. Clinicians also feared that switching combination classes or adjusting dosages might confuse or frustrate patients, resulting in misuse, nonadherence, or abandonment of care. ‘’The last thing you want is for someone to get frustrated and stop taking their meds. If they don't understand, they might take too much – or just give up. Starting with a fixed combination can create that confusion. (Cardiologist) Lastly, although FDCs are typically formulated with long‐acting agents to ensure 24‐hour coverage, clinicians voiced concerns that administering two agents simultaneously could lead to waning coverage overnight, contributing to morning hypertension. 3.2.4. Pharmacists and Nurse Practitioners Champion FDCs In contrast to clinicians, pharmacists and nurse practitioners were widely familiar with FDCs and expressed strong confidence in their clinical benefits (Table S1C ). As one pharmacist shared: “There's clear data showing no increased rate of side effects or intolerability, and that it's actually better for patients – you can reach goals faster. The benefits are real: lower pill burden, better adherence, and just one copay instead of two. We all know hypertension is a chronic disease, and patients will need multiple medications over time. So, if we can start with two lower doses of meds with different mechanisms, we might get better blood pressure control while lowering the risk of side effects.” (Clinical Pharmacist) Pharmacists and NPs also described FDCs as generally affordable to patients: “I work with insurance quite a bit. [Initially,] I wasn't familiar with how well they were actually covered. I was asked to help with coverage analysis, and I realized most FDCs are very well covered. There are just a few that are branded only and have poor coverage. So, I try to avoid those, especially if the individual components are available as generics at lower cost to the patient. But like I said, almost every FDC is now available as a generic, so it's rarely an issue – just in a few cases where we've exhausted other options.” (Clinical Pharmacist) 3.2.5. Pharmacists and Nurse Practitioners Favor FDCs Over Stepwise Monotherapy Reflecting on their hypertension treatment approach, pharmacists and NPs shared that they had increasingly favored FDCs in recent years, a shift driven by specialist guidance and the rollout of the UC Way Hypertension Medication Algorithm. They emphasized that FDCs are especially valuable for patients facing barriers to care. As one pharmacist explained: “I'd say the majority of patients would benefit from FDCs – especially those on multiple medications, with comorbidities, or lower health literacy. For patients whose first language isn't English or who struggle to navigate the healthcare system, it's much easier to manage one prescription than two…Oftentimes, patients deal with asynchronous prescriptions and end up making multiple pharmacy trips each month for their blood pressure meds. Switching to an FDC simplifies that – they can make one trip and pick up everything. I think all patients could benefit from FDCs, though I know there are still challenges to starting them.” (Clinical Pharmacist) 3.3. Pharmacists and Nurse Practitioners Reframe Clinicians’ Concerns About FDC Dosage Flexibility and Safety When presented with clinicians‘ concerns around dosage inflexibility, adverse effect management, and patient confusion, pharmacists and NPs responded with reassurance grounded in their experiences, observations, and practical strategies. Both stakeholders regularly described side effects as infrequent and manageable, and noted that FDC dosages could be adjusted without much difficulty. As one participant shared: “If a patient has an adverse effect to one component – say, we think it‘s the hydrochlorothiazide – we might switch to losartan alone. But I’m not hesitant to start with the fixed‐dose combo, especially since we begin at really low doses. I usually start with half a tablet and titrate up slowly. Adverse effects aren't that common in my experience. And if they do occur, we can always reverse course – split it out to losartan alone and consider trying another agent, like a calcium channel blocker.” (Clinical Pharmacist) 3.3.1. Pharmacists Primary Concern With FDCs: Providing Adequate Patient Education Pharmacists‘ major concern with FDCs was providing adequate patient education and trust‐building to mitigate the risks of negative patient experiences. One participant noted: ’‘My main concern isn’t about blood pressure dropping too low – it‘s more about the patient experience. If they have a side effect, they may associate it with the entire FDC and become unwilling to try another therapy, even if only one component was responsible. That makes it harder to find an alternative, especially if one of the agents was already effective. It becomes more about patient education – explaining, for example, that ankle swelling might be from the amlodipine – and convincing them to try a different combination. So, it’s less about me identifying the culprit and more about helping the patient stay open to options that will get them to goal with minimal side effects.‘’ (Clinical Pharmacist) These conversations consistently demonstrated pharmacists’ leadership in advocating for FDCs across the health system, as affirmed by other population health leaders: “ Our pharmacists have been quite big advocates for thinking about how this fixed‐dose combinations might help address some of the cost concerns, potentially being lower cost by having a single pill instead of two separate prescriptions. They also highlight the convenience in terms of refills and adherence.” (Nurse Practitioner) 3.3.2. Reflections on Patients’ perceptions of FDCs Although patients were not directly interviewed, providers also reflected on patients’ reactions to FDCs. Most described patients as broadly amenable to FDCs, citing appreciation for the reduced burden and improved adherence. As one clinician shared: “My patients prefer fewer pills. Usually, I hear, ‘Oh you mean I can take one pill instead of two?’ I don't think I've ever gotten pushback.” (Cardiologist) Nonetheless, providers identified several patient‐level barriers to FDC use. Patients who feared adverse effects or distrust pharmacotherapy often preferred stepwise monotherapy to better identify the agent causing side effects. Others who were on a stable regimen of single agents were hesitant to change their treatment approach to include FDCs. Some patients also found FDCs too large to swallow. “Some patients view medications as toxic or poisonous. There's a lot of hesitancy and mistrust toward pharmaceuticals – many don't want to start any medication, let alone two. While I think these patients could benefit from an FDC, when negotiating a care plan, I choose to increase the dose of a single agent rather than introduce two drugs to maintain trust.” (Clinical Pharmacist) 3.4. Recommendations for Health System Leaders to Promote FDC Utilization Stakeholders collectively proposed a range of actionable strategies to increase FDC prescribing and uptake. Recommendations fell into five overarching domains (Table 3 ). Providers consistently emphasized the need to incorporate FDC exposure into medical, pharmacy, and nursing curricula and linking such exposure to the underlying concept of timely medication intensification. Stakeholders argued this would shift prescribing norms before monotherapy‐reliant habits are ingrained. “[One medical school] is going to be teaching this to their students – medical students and residents – so they learn about fixed‐dose combinations and their benefits before they start practicing. I think that's a great strategy. It's hard to teach an old dog new tricks, so starting while everything's still fresh just makes sense.” (Clinical Pharmacist) Clinicians advocated for greater integration of FDCs into the electronic medical record through decision‐support tools and SmartSets to prompt FDC consideration, reduce cognitive burden of identifying appropriate combinations, and encourage medication intensification and adherence to the UC Way Hypertension Algorithm. When ordering, you have to know that you're looking for an FDC. There's not an alert or prompt that says, ‘consider a single‐dose combination for this patient.’ That would help. Right now, you have to be intentional—and know what's in the combination. An alert or guide would be useful if, when a clinician types in a monotherapy, it suggests a fixed‐dose combination – or flags that a patient on two components might be eligible for a combo.‘’ (Clinical Pharmacist) Providers reiterated the value of expanding team‐based care models to existing hypertension workflows to delegate medication intensification to pharmacists, nurses, and medical assistants and improve hypertension control rates. “Honestly, I think you need to take it out of the PCP's hands. Nurses and pharmacists are better at following guidelines and saying, ‘This patient is above target – let's increase meds.’ PCPs are distracted. Sometimes they think, ‘This doesn't apply to my patient,’ or feel they don't need to follow every guideline. Shifting hypertension management to others can really help.” (Internal Medicine‐trained Primary Care Provider) Multiple stakeholders, including one health system executive, stressed the importance of institutional leadership to effectively normalize FDC use. They recommended endorsing FDC prescribing, aligning existing incentive structures to promote FDC utilization, and using data to identify eligible patients on dual monotherapy, monitor adoption trends, and implement site‐level quality improvement initiatives. “Like most things, you'd have to get the leaders of these clinical groups to endorse it. If it was very clear this is a better way to treat blood pressure, then we could say: to optimize your blood pressure control statistics, this would be rational.” (Provider and Health System Executive) “We have a PCP incentive plan. It's part of their bonus structure. But there's no incentive around how the blood pressure is controlled. Some patients don't need drugs – others do. We're not incentivizing a particular strategy.” (Provider and Health System Executive) “It's about really drilling down into a particular practice and identifying where performance is trending in the right direction. And then asking: is it something specific to that department or clinic? Is it something about the way a certain group of physicians is operating? That's where a population health or quality improvement team can come in – work with the clinicians and really dig into what's working. Is it an education piece? A workflow piece? Or maybe it's a combination of factors, including some type of technology or decision‐support tool. That's the improvement science approach: using data to guide where you invest your time, figuring out what's working well, and then taking that learning and seeing what you can spread to other clinics or practices across the system.” (Nurse Practitioner) To achieve lasting behavioral change, participants emphasized the need for a normative shift through routine socialization strategies, such as the appointment of FDC “champions,” facilitating peer‐to‐peer check‐ins, sharing stories of successful patient outcomes tied to FDCs, and offering CME‐accredited sessions. Participants emphasized that these opportunities must make the clinical and practical case for FDCs, highlight evidence of their therapeutic efficacy, and address clinicians’ perceived risks. “We're asking providers to make a big behavioral shift, and they probably need more than an email or handout. What's effective – though not true for everyone – is hearing from a trusted peer. In our case, a physician and a clinical pharmacist were both involved. That gave two different voices and perspectives. Having an MD talk to other MDs – sharing literature and personal stories – adds legitimacy.” (Clinical Pharmacist) 4. Discussion Given markedly low FDC utilization across UCH and the urgent need to improve BP control, we conducted in‐depth semi‐structured interviews with clinicians, pharmacists, population health leaders, and health system stakeholders to identify barriers and develop recommendations for change. These findings are summarized in Figure 1 . FIGURE 1. Open in a new tab Conceptual model of provider perspectives, structural barriers, and recommended strategies for health systems to increase fixed‐dose combination utilization. This investigation revealed substantial variability between clinicians’, pharmacists’, and nurse practitioners’ awareness, attitudes, and prescribing patterns related to FDCs. Clinicians reported minimal use of FDCs and expressed limited familiarity with their therapeutic benefits, availability, and affordability. Even among clinicians who used FDCs, participants reported a prevailing sense that FDC use remained uncommon within their departments and among their colleagues. In contrast, pharmacists consistently self‐identified as major proponents of FDCs, demonstrated high familiarity with the clinical and cost advantages of FDCs, and were informed of findings from the literature [ 15 , 16 , 17 , 19 , 21 , 22 ]. Pharmacists also reported that their colleagues broadly prioritized FDC use in practice. Prominent considerations limiting FDC prescribing among clinicians were perceptions that FDCs were associated with dosage inflexibility and challenges managing adverse effects. Clinicians expressed concern that, in the wake of an adverse effect following FDC use, they may be unable to discern the offending agent within the combination or adjust the regimen appropriately. Furthermore, clinicians feared that such experiences could erode patient trust and contribute to nonadherence or disengagement from care. Pharmacists acknowledged these risks but emphasized that FDCs offer adequate flexibility across drug classes and dosages. They viewed clinicians’ concerns as misconceptions stemming from limited exposure and experience with FDCs. Instead, pharmacists’ primary concern was ensuring patients were well‐informed and followed up to prevent such incidents. These divergent perceptions of risk were reflected in practice: while all pharmacists had shifted their hypertension treatment strategy to prioritize FDCs, many clinicians continued to favor stepwise monotherapy and expressed hesitation adopting alternative approaches. Pharmacists recognized this reluctance and described frequently transitioning eligible patients from monotherapy‐based regimens prescribed by clinicians to FDCs. From their perspective, these transitions were typically well‐tolerated and appreciated by patients for the simplified regimen and lower copays. Several pharmacists expressed that, during such transitions, their clinician colleagues had been unaware of FDCs as an available therapeutic option. Our findings suggest that these differences in perception and practice between physicians and pharmacists/nurse practitioners stem from two primary factors. First, although robust data demonstrate that early treatment with FDCs can result in faster BP control, lower required doses through synergistic mechanisms, reduced side effects, and lower overall costs, [ 21 , 40 , 46 , 47 , 48 ] recognition of the evidence base for FDCs remains inconsistent among physicians. Pharmacists and nurse practitioners, in contrast, appeared to have greater exposure to the therapeutic and practical advantages of FDCs in routine practice. Second, structural barriers (Table S1A ) continue to reinforce monotherapy‐first prescribing and constrain FDC prescribing. FDCs have historically received limited emphasis in medical and pharmacy training, where the dominant paradigm has been “start low and go slow” with stepwise monotherapy. Furthermore, while pharmacists operate in professional cultures that increasingly prioritize FDCs, FDCs are often not regularly considered in the clinical routines and environments of physicians. This is in part due to clinical workflows characterized by time constraints, competing patient needs, and complex social challenges – such as housing insecurity – that limit clinicians’ ability to prioritize medication intensification or consider unfamiliar prescribing strategies [ 49 , 50 , 51 ]. Moreover, within health systems serving diverse populations with multiple payers, formularies, and coverage plans, clinicians face barriers verifying FDC availability and affordability due to opaque formularies, lack of integration into decision‐support tools, and limited leadership endorsements. Without clear incentives or performance metrics aligned with FDC utilization, uptake remains low. These dynamics contrast to well‐resourced, vertically integrated systems, where unified formularies, strong leadership support, and standardized care models have enabled wider FDC adoption and BP control rates approaching 90% [ 52 , 53 , 54 ]. To address these barriers, past initiatives – including the development and implementation of The UC Way Hypertension Medication Algorithm – have sought to promote FDCs as a first‐line therapeutic option but have faced challenges unique to multi‐payer systems. A central strength of this initiative was the inclusion of a multi‐payer cost analysis, including both Medicare and Medicaid plan considerations, which informed therapeutic recommendations aligned with clinical evidence, access, and affordability. Selecting an ARB/Thiazide FDC as first‐line therapy balanced efficacy with broad insurance coverage across Medicare, Medicaid, and commercial plans. However, variability in formularies (shaped largely by large national health plans) and prescribing practices at sites inevitably create variability in the speed and extent of algorithm adoption and ultimately reduce clinical impact. Likewise, as clinicians emphasized, institutional cultures may not consistently reinforce guideline adherence, favoring individualized decision‐making over standardized treatment pathways. Moving forward, we propose several stakeholder‐informed strategies that health systems can implement to systematically address these barriers and increase FDC uptake (Table 3 ). First, FDCs must be integrated in early medical and pharmacy education. Trainees must learn the importance of timely medication intensification and the benefits of initiating dual therapy, preferably as FDCs, for effective hypertension management [ 19 , 20 , 21 , 22 ]. Second, electronic medical records should incorporate decision‐support tools and SmartSets that prompt FDC consideration at the point of care. One successful example of this is the recent integration of The UC Way Hypertension Medication Algorithm into SmartSets at select UC sites as of July 2025. To address clinical inertia, one of the foremost barriers to BP control [ 10 , 46 ], leadership should evaluate existing hypertension workflows and invest in team‐based care models. These models, which integrate pharmacists, medical assistants, and nurses, have been shown to improve hypertension outcomes by distributing responsibility for medication intensification and transmitting best practices across providers. In fact, The AHA and American Medical Association recommend team‐based care as the most effective strategy for blood pressure control, with analyses illustrating average systolic BP reductions of 7–10 mmHg and increased BP control rates when pharmacists and nurse practitioners are empowered to titrate medications and provide follow‐up [ 7 , 9 , 55 , 56 ]. Third, health system leadership should formally endorse FDC, recognize evidence of their therapeutic and cost advantages, and implement system‐level accountability mechanisms. These include tracking FDC utilization rates across departments and clinical sites; providing transparent progress updates; offering performance incentives, and modeling after high‐FDC‐uptake institutions [ 52 , 53 , 54 ]. A broad normative shift is essential to normalize FDC prescribing. Each clinical site should appoint FDC “champions” to lead formal or informal peer discussions, share success stories, and reinforce FDCs as a viable first‐line option. Such leadership has been associated with improved uptake of team‐based interventions, more consistent medication intensification, and improved care outcomes by establishing a culture of shared responsibility for medication management and reinforcing guideline adherence [ 9 , 57 ]. Novel incentive structures should prioritize FDC initiation for patients with BP >20/10 mmHg above target, especially for patients with BP >140/90 mmHg in accordance with the most recent AHA/ACC guidelines [ 7 , 26 ]. CME‐accredited educational sessions can incentivize engagement. Notably, the UC's Hypertension Medication Workgroup has already developed supporting tools, including announcement letters, infographics, patient handouts, email templates, recorded tutorials, and a reference slide deck, which should be disseminated to support uptake. Finally, addressing clinician hesitancy is paramount. Systems must meet providers where they are, acknowledge underlying concerns, and equip clinicians with peer support and clinical tools that clarify the benefits of FDCs. Crucially, the central challenge with decision‐support tools and team‐based care models lies in their investment requirements. Some of these benefits may be achievable at lower cost through AI‐enabled clinician decision support and remote patient monitoring (RPM). Applied to hypertension management, such tools could help identify patients meeting criteria for initial combination therapy, alert clinicians to opportunities for FDC substitution when multiple single agents are prescribed, and track adherence or blood pressure response in real time. Yet these technologies carry substantial risks: environmental costs from energy‐intensive computation; [ 58 , 59 ] equity concerns due to unequal access to digital tools that may accentuate existing health disparities; algorithmic bias, stemming from non‐representative training data, resulting in mismanagement of marginalized populations; and tangible clinical risks when algorithmic noise obscures meaningful signals [ 60 , 61 , 62 ]. As these tools become increasingly considered for chronic disease management, future implementation efforts must weigh clinical and financial benefits against the environmental and social costs by adopting equity‐centered design, rigorous bias mitigation, and transparent auditing. Safeguards and strategies must be developed that explicitly monitor for unintended consequences, prioritize equitable access to technology, and mitigate these tradeoffs to ensure that AI technologies deliver meaningful improvements without exacerbating existing challenges [ 58 , 59 , 61 ]. This study's findings are consistent with prior qualitative and quantitative studies identifying provider concerns around dosage flexibility, preference for titrating individual agents, lack of awareness of available FDC products, perceived or real insurance coverage limitations, and clinical inertia [ 32 , 63 , 64 ]. However, our investigation advances the literature in several ways. It is the first to apply qualitative, interview‐based inquiry to examine structural barriers to FDC utilization; draw from a diverse cohort of clinicians across specialties, pharmacists, population health experts, and institutional leaders; and generate systemwide, stakeholder‐informed recommendations. This multi‐level perspective offers a deeper, more actionable understanding of the barriers and opportunities to improve FDC utilization. This study has several limitations. First, it is subject to selection bias, as participants who chose to be interviewed may have had a particular interest in FDC utilization. This potentially skews the results toward more favorable or more critical viewpoints. For instance, pharmacists who participated may be more enthusiastic about FDCs than the broader population. Second, all participants were recruited from UC Health – a large, academically affiliated health system with diverse institutional cultures and patient populations. Findings may not be generalizable to non‐academic or community‐based settings and may reflect regional or geographic biases, including heightened awareness of FDCs or perceived barriers unique to UC Health. Third, although we sought to recruit a diverse cohort of participants – initially contacting thirty‐five health professionals directly engaged in hypertension care or hypertension‐related population health initiatives using purposive and snowball sampling, the resulting sample disproportionately represented Caucasian and Asian providers. While race is a social construct without genetic basis, limited racial and ethnic representation constrains transferability and risks overlooking the perspectives of underrepresented communities [ 65 , 66 ]. Lastly, the study did not include direct patient interviews, and patient perspectives were captured only indirectly through provider reports. Given that patient's experiences, concerns, and acceptance of FDCs are central to increasing uptake, future qualitative research should directly examine patient perspectives to better characterize patient‐level barriers and facilitators to FDC utilization. As one clinician emphasized, the first open, academic health system to address these structural barriers will lead the way in improving hypertension treatment and management nationally. In the short‐term, we envision these proposed strategies strengthening provider awareness, shifting prescribing behaviors, and increasing FDC utilization. In the long‐term, broader adoption of FDCs will improve BP control rates and therefore reduce the incidence of ischemic heart disease, stroke, dementia, chronic kidney disease, heart failure, and premature mortality. For the billions affected by hypertension, optimizing FDC utilization is not merely a clinical improvement. It is a structural opportunity to advance health equity, reduce racial disparities, lower healthcare costs, and alleviate the immense health, social, and economic burdens of uncontrolled hypertension. Failing to act on this opportunity would represent a profound failure to address one of the most pervasive and consequential epidemics of the century. Author Contributions Conceptualization: Pranay Narang and Sandeep P. Kishore. Methodology: Pranay Narang, Sandeep P. Kishore, Rohini Haar and Neema Rashidi. Investigation: Pranay Narang and Sandeep P. Kishore. Data Curation: Pranay Narang, Josselyne Marquez and Sandeep P. Kishore. Formal Analysis: Pranay Narang, Josselyne Marquez and Sandeep P. Kishore. Validation: Pranay Narang, Josselyne Marquez, Neema Rashidi, Sandeep P. Kishore and Rohini Haar. Writing – Original Draft: Pranay Narang and Sandeep P. Kishore. Writing – Review and Editing: Pranay Narang, Sandeep P. Kishore and Rohini Haar. Supervision: Sandeep P. Kishore and Rohini Haar. Project Administration: Pranay Narang, Sandeep P. Kishore and Rohini Haar. Funding Acquisition: None. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors. Disclosure Dr Kishore reports advisory fees from Redesign Health; grants and equity in CareX.AI. Ethics Statement Ethical approval was obtained from the Institutional Review Boards of the University of California, Berkeley and the University of California, San Francisco. Supporting information Supporting Information : jch70300‐sup‐0001‐figureS1.docx JCH-28-e70300-s001.docx (3.3MB, docx) Appendix A. Semi‐structured interview guide Title of Investigation : Exploring Barriers to Fixed‐Dose Combinations Utilization across the UC Health System Introduction: Hello, my name is X. I'm a [describe position], and we're conducting a study investigating the barriers limiting prescribing and utilization of Fixed‐Dose Combination (FDCs), or Single‐Pill Combinations (SPCs), as a dual therapy for hypertension across the UC Health System. Thanks so much for being willing to meet and share your perspective. I am eager to hear about your experience treating and managing hypertension and the role that FDCs may play, if at all, in your practice. The information you share today will be anonymous. Confirmation of Informed Consent : Questions Responses Name of Interviewer Date of Interview mm/dd/yyyy Total duration of interview Hour (s): Minute (s): Data Recording Audio, video, hand written notes, other: Consent Yes > verbal consent to participate in study documented Yes > verbal consent to audio record documented No > DO NOT PROCEED Any questions before we begin the interview? Open in a new tab Let me know when you're ready to begin. First, I would like to begin by collecting some demographic information. Demographics & Background : Question Response What is your age? What is your gender identity? What is your race or ethnicity? What type of healthcare provider are you? (MD, DO, NP, Pharmacist, etc.) What is your specialty or training background in? How long have you been practicing for? How long have you been treating patients with hypertension? Are you eligible to prescribe antihypertensive medications? Can you please describe your current role and what you do? What setting/practice do you work in? (outpatient setting, inpatient setting, academic, private practice, FQHC, etc.) Can you please describe the socioeconomic characteristics of the patient populations that you serve? What percent of the patients that you serve would you estimate have a diagnosis of hypertension? Do your patients primarily present with a previous diagnosis of hypertension? Or do you more often diagnose patients with hypertension? Open in a new tab I'd like to learn more about the treatments you may consider in your practice. Hypertension Treatment Prescribing Patterns When you find yourself newly diagnosing a patient with hypertension, what is the first line treatment that you consider prescribing? Generally, do you prescribe one agent or two agents? Over the course of your years practicing, would you say you prescribe monotherapies more than dual therapies early on, or does your approach prioritize using two medications early on? Awareness & Familiarity with FDCs (e.g., therapeutic and cost implications) Have you heard about Fixed‐Dose Combinations (FDCs) as a tool to achieve BP control when treating patients for hypertension? Can you tell me a little bit more about what you've heard of FDCs? Do you think FDCs are associated with better HTN control than the alternative, stepwise approach where one prescribes monotherapies for hypertension and increases the dosage, possibly adding a medication if needed? How do you typically use Fixed‐Dose Combinations? Can you give me an example of a time you recently used them? Where did you learn about FDCs? Do you feel your medical training and education adequately prepared you to consider utilizing FDCs as a dual therapy for hypertension? FDC Utilization in Clinical Practice How often would you say you prescribe FDCs in a given week? What percent of your patients would you estimate are on FDCs? How often would you say you make adjustments to patients’ medication regimens to include FDCs in a given week? What are some of the common FDCs that you prescribe? Provider Perceptions & Concerns with FDCs: Ideal Indication, Adverse Effects/Titratability, Costs FDC Indications Do you think most patients with hypertension should be treated with FDCs? What patient populations should not be treated with FDCs? What patient populations do you consider appropriate for prescribing FDCs? Do you think FDCs should be started anew for a patient that is newly diagnosed with hypertension? Or should FDCs be switched to only after patients have adjusted to a new medication regimen with established classes and doses and minimal AEs? Concerns: Adverse Effects, Titratability, Cost When prescribing two separate monotherapies instead of an FDC, could you describe some of the reasoning behind that decision? Do you feel that FDCs offer adequate flexibility when it comes to titrating and modifying doses until the intended BP effects are achieved without adverse effects? When considering FDCs, do you worry about managing adverse effects? Have you seen any adverse effects after prescribing FDCs to patients? When considering prescribing FDCs, do you worry about costs? Do you know which insurers cover FDCs and which do not? Or the extent to which FDCs may be covered? Patient Perceptions: Costs and Adverse Effects Can you describe some concerns that patients have expressed to you regarding FDCs in your practice? From your experience, have patients expressed concern about costs? What about adverse effects? What about intensifying medication too quickly? Are patients generally receptive or reluctant to utilize FDCs when you prescribe it? Systemic & Structural Barriers Do your colleagues use FDCs? Why or why not? If your colleagues prefer other therapeutic agents, why might that be? Is there a leading voice in your department who advocates for FDCs? Who do you turn to in your department if you have questions about antihypertensive treatments or best practices for hypertension? Are you aware of any existing EHR‐based alert or tool that may prompt you to consider FDCs? Do you think an alert would be an effective way to increase utilization? Given that insurers institute formulary changes annually that may alter coverage for antihypertensive agents, do you ever find yourself concerned about whether or not patients’ antihypertensive medications lose coverage? How do you keep up to date with formulary changes? Does your institution send out any such updates on coverage modifications or formulary changes? Have you heard about Real‐Time Prescription Benefit, an EHR‐tool that provides insight into whether or not certain FDCs or drugs are covered by a patient's insurer? Is there a general cultural norm of prioritizing certain treatments? Have you heard about the UC Way Hypertension Medication Algorithm? Are you aware that FDCs are prominently featured in this guideline? Recommendations for Improving FDC Utilization What do you think could be incorporated into your clinical workflow – the setting that you work or the rhythm of your day or your institution more broadly – to promote the utilization of FDCs? Conclusion : Question Response Is there anything else you would like to say or add to our conversation? Finally, I just want to confirm that I have your consent to include your responses and feedback in the data analysis of this investigation. Could you please reaffirm your consent? 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