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• W2891165804 abstract "The management of hypertension has been a major public health success, and large integrated health care systems now achieve control in up to 80% of their hypertensive patients.1, 2 This success is now challenged by the new 2017 ACA/AHA Hypertension Guideline.3 As demonstrated by a new article by Ritchey et al4 in this issue of the Journal of Clinical Hypertension, under the new guidelines, blood pressure control rates in the United States have decreased by 21.1% and initiation or intensification of pharmacologic therapy is recommended for 57.8 million adults. The bulk of these people are already receiving care from a clinician. This suggests that the major challenge in hypertension control will remain to overcome clinical inertia.5 It is commonly said that if you cannot measure care, you cannot improve it. Fortunately, much has been learned over the past 15 years about clinical inertia and its measurement that will help us to improve hypertension care. The term clinical inertia, the failure of health care providers to initiate or intensify therapy appropriately during visits, dates back to a 2001 article by Phillips et al and was based on their long-standing observations of diabetes care.6 Hypertension clinicians, though, have long recognized that inertia is an important feature of blood pressure management. Landmark clinical trials such as the Hypertension Detection and Follow-up Program were predicated on the inertia of usual community care in comparing it to a systematic stepped-care approach.7 An observational study of hypertension care from the early 1990s demonstrated that patients with elevated blood pressures had recurrent visits with few changes in therapy.8 Studies from many different settings and countries have demonstrated the existence of clinical inertia. Reasons for clinicians' not intensifying therapy have been studied, and a detailed typology for these reasons has been developed.9 Reasons for clinical inertia include unwarranted optimism, overconcern about adverse effects, and willingness to further negotiate care. It has been suggested that clinicians may not be intensifying therapy due to uncertainty as to what is the patient's “true” blood pressure.10 Yet inertia has been noted even in the setting of a clinical trial following a rigorous protocol for blood pressure determination. Among ALLHAT participants with uncontrolled hypertension, the percent whose regimens were intensified leveled off at only 30% by the second year of the study.11 Competing demands for clinician attention in managing other comorbid conditions, especially those conditions unrelated to cardiovascular disease, may also explain the failure to address elevated blood pressures.12, 13 In one study, each additional unrelated comorbidity was associated with a 15% lower odds of treatment intensification at a given visit.13 Clinical inertia could also represent appropriate inaction in the setting of patient nonadherence to medications.14 Studies that have examined clinical inertia and nonadherence in the setting of uncontrolled hypertension, though, have generally found a greater impact from clinical inertia.15 While uncertainty as to the “true” blood pressure, nonadherence, and competing demands may explain some clinical inertia, they are unlikely to fully explain this common problem. Clinical inertia can be readily evaluated using measures of treatment intensity. At least four different approaches to describing treatment intensity have been used in the literature. The most commonly used approach is to look at individual visits with uncontrolled hypertension and determine whether treatment intensification occurred.16 The resulting measure is a simple percentage of uncontrolled visits with an intensification of therapy. Recognizing that decisions to intensify therapy may happen over several visits, a second approach used by Okonofua et al considers all visits over some defined time period such as a year.17 A treatment intensification score is calculated for each patient as the observed number of visits with an increase in therapy minus the number of visits with uncontrolled blood pressure divided by the total number of visits. This results in a score ranging from −1 to +1 with higher values indicating more intensive therapy. The likelihood of intensifying therapy at an individual visit may vary depending on patient characteristics such as how high the blood pressure is and specific comorbidities. Therefore, a third approach also looks at care over a defined time period but uses a regression model to calculate the expected number of increases in antihypertensive therapy.8 The treatment intensity score is calculated for patients as the observed minus the expected number of increases in therapy divided by the total number of visits, and also can range from −1 to +1. A final approach considers clinical inertia to be present whenever a patient has uncontrolled blood pressure and is not on an adequate regimen of 3 or more medications.15, 18 Dosage of medications and use of a thiazide diuretic may also be considered in defining an adequate regimen. A simple percentage of uncontrolled patients not on 3 medications is calculated using this approach. The validity of these measures of treatment intensification has been repeatedly demonstrated by their ability to predict blood pressure control.8, 17 Higher treatment intensity in observational studies is associated with a greater likelihood of achieving blood pressure control. Only one study19 has compared different measures of treatment intensification and found that the approach employed by Okonofua et al was the strongest predictor of blood pressure control, suggesting it may be the preferred approach. These measures of treatment intensity have been used to examine variations in hypertension control. For example, among people with diabetes, worse control was associated with less intensive hypertension therapy.20 However, black hypertension patients have worse control but may be more likely to have their treatment appropriately intensified.21 This suggests that other reasons may come into play when trying to understand uncontrolled hypertension in blacks. Less is known on the use of these measures to profile individual clinicians or health care settings. It would be expected that some clinicians would be more proactive in addressing elevated blood pressures than others. Yet the extent to which clinicians vary in their practices, and whether interventions can be successfully targeted to those clinicians exhibiting the greatest inertia on these measures, requires future evaluation. Importantly, clinical inertia can be overcome. A wide variety of interventions have been evaluated in clinical trials and summarized in systematic reviews.22 Interventions may focus on clinicians, patients, or system factors and often incorporate education, audit with feedback, and reminders. The use of physician extenders, such as nurses and pharmacists, following well-defined treatment algorithms has long been recognized as an especially successful approach.23 National success in overcoming clinical inertia has been well demonstrated in epidemiological studies with improved blood pressure control associated with large increases in the use of multiple antihypertensive medications.24 This suggests that we currently have many of the tools that will be needed to overcome clinical inertia in meeting the challenge posed by the 2017 ACA/AHA Guideline. As described by Ritchey at al., tens of million adults with hypertension will need intensification of their blood pressure therapy. Education of patients and clinicians will be critical. This should be combined with ongoing evaluations of blood pressure control rates along with measurements of clinical inertia and time to achieve blood pressure control.25 Berlowitz has no conflicts of interest to report." @default.
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• W2891165804 date "2018-09-08" @default.
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• W2891165804 title "Clinical inertia and the 2017 ACA/AHA guideline" @default.
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• W2891165804 doi "https://doi.org/10.1111/jch.13373" @default.
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