It's Time to Overcome Clinical Inertia

Hypertension is the most important health problem that clinicians don't manage well. Blood pressure control is particularly important for patients with diabetes (1), but providers may be less likely to intensify therapy for hypertension than for hyperglycemia (2), and antihypertensive therapy in patients with diabetes is sometimes less intensive than in patients without diabetes (3)—the opposite of what it should be. In many patients, blood pressure levels remain above goal because providers do not initiate or intensify therapy when clinically indicated. We have characterized this problem as “clinical inertia” (4).

Despite recognition that suboptimal management of hypertension often reflects inadequate intensification of therapy, overcoming clinical inertia to improve blood pressure has been difficult; in 1 study, feedback on performance improved hemoglobin A_1c but had no effect on blood pressure (5). To overcome clinical inertia, we must understand its causes. Clinical inertia is not linked to patient sex or race (6), but it has been associated with a history of medication nonadherence (7), providers claiming satisfaction with blood pressure control (8), and the number of comorbid diseases (9). Such observations suggest that clinical inertia may reflect uncertainty about the level of blood pressure that merits intensification and preoccupation with the patient's other problems.

Two recent Annals papers (10, 11), 1 in this issue, provide information about the factors that contribute to clinical inertia in hypertension management. In this issue, Kerr and colleagues (10) used chart abstraction and provider questionnaires to assess the management of 1169 diabetic patients in a Veterans Affairs facility who had an initial clinic blood pressure reading of 140/90 mm Hg or greater. Despite an average systolic blood pressure (SBP) of 154 mm Hg and previous year SBP of 145 mm Hg, only 49% of patients overall …