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Editorials |

It's Time to Overcome Clinical Inertia

Lawrence S. Phillips, MD; and Jennifer G. Twombly, MD, PhD
[+] Article and Author Information

From Emory University, Atlanta, GA 30322.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Lawrence S. Phillips, MD, Division of Endocrinology, Emory University, 101 Woodruff Circle, WMRB Room 1027, Atlanta, GA 30322; e-mail, medlsp@emory.edu.

Current Author Addresses: Dr. Phillips: Division of Endocrinology, Emory University, 101 Woodruff Circle, WMRB Room 1027, Atlanta, GA 30322.

Dr. Twombly: Division of Endocrinology, Emory University, 101, Woodruff Circle, Room 1301, Atlanta, GA 30322.


Ann Intern Med. 2008;148(10):783-785. doi:10.7326/0003-4819-148-10-200805200-00011
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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).

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Should we treat hypertension more like diabetes?
Posted on May 26, 2008
Sam F Carter
Murfreesboro Medical Clinic
Conflict of Interest: None Declared

I am puzzled by the recommendation of Phillips and Twombly (1) to change antihypertensive therapy based on single blood pressure measurements and by their dismissal of home monitoring, given the marked variability of blood pressure over time, especially in older patients with systolic hypertension. I have observed fluctuations in systolic pressure of up to 100 points in 24 hours in clinically stable patients in both inpatient and outpatient settings. If I have verified in my clinic the reliability of a patient's blood pressure machine, is the average of multiple home measurements not more important than a single clinic measurement?

Changing an antihypertensive regimen based on a single blood pressure reading appears to me analogous to changing a diabetic regimen based on a single blood sugar without looking at the overall pattern and A1C. The cautious approach of the clinicians in the overdue study by Kerr and colleagues in the same issue (2) appears even more appropriate if we restate their uncertainty about the "true" blood pressure (as blood pressure truly does fluctuate) as uncertainty about the average blood pressure. Pursuing the analogy to diabetic management, would it not be a logical approach to encourage most hypertensive patients to perform home monitoring and to base treatment decisions on the average blood pressure over several weeks or months?

1. Phillips LS, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med. 2008;148:783-785.

2. Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717-727.

Conflict of Interest:

None declared

Clinical inertia or just following guidelines?
Posted on May 24, 2008
Robert C Sherrick
Kalispell Diagnostic Service
Conflict of Interest: None Declared

In their comments on the article concerning clinical inertia in the treatment of hypertension in diabetic patients (1), Phillips and Twombley suggest that "every occurrence of blood pressure above goal should prompt intensification of treatment." This conflicts with the current recommendations of the Seventh Joint Commission (JNC7), which state:

"Self-monitoring of BP at home and work is a practical approach to assess differences between office and out-of-office BP prior to consideration of ABPM. For those whose out-of-office BPs are consistently <130/80 mmHg despite an elevated office BP, and who lack evidence of target organ disease, 24-hour monitoring or drug therapy can be avoided."(2)

Rather than suffering from clinical inertia, clinicians may be simply following the guidelines. Until the guidelines are revised to clarify how to deal with discrepancies between office and home blood pressure readings, clinicians cannot be faulted for following them.

(1) Philips, LS, Twombley, JG. It's Time to Overcome Clinical Inertia. Ann Intern Med, 2008, 148:783-785

(2) Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003 Dec;42(6):1206-52

Conflict of Interest:

None declared

Running the number ignores the realities of primary care
Posted on June 17, 2008
Sandeep Vijan
Ann Arbor VA HSR&D
Conflict of Interest: None Declared

In their recent editorial, Phillips and Twombly suggest that clinical inertia is easily overcome if providers "run the numbers first and deal with blood pressure and glucose before asking about other problems."(1) While managing vascular risk factors is extremely important in reducing the risk of diabetes complications, their approach dramatically oversimplifies the realities of clinical care.

Kerr and colleagues show that clinician and patient uncertainty around blood pressure management is an important determinant of treatment decisions.(2) Uncertainty can take many forms, from belief in the level of evidence supporting guidelines to concern about side effects and measurement error. As we noted in our ACP evidence review on managing blood pressure in diabetes,(3) there are no clinical trials showing benefit to treating to a systolic blood pressure goal of less than 140 mmHg. The supporting evidence for lower targets is purely observational, and the possibility of harming patients by overtreating diastolic blood pressure is real.(4) Nevertheless, Phillips and Twombly recommend that every time a blood pressure reading is elevated, clinicians should intensify therapy. This approach promotes potentially harmful polypharmacy, given that most patients with diabetes require at least 2-3 blood pressure medications,(3) and also increases the risk of non- adherence due to side effects and cost.

Further, treating every blood pressure above goal markedly oversimplifies the realities of blood pressure measurement and variability. Consider the related issue of cholesterol management. In a recent issue of Annals, it was shown that repeated cholesterol measurement leads to more noise than signal, and thus causes unnecessary medication adjustment.(5) Given the vagaries of blood pressure measurement and phenomena like white coat hypertension, this is likely to be an even larger issue for hypertension.

Finally, we strongly object to the concept of "running the numbers" first, which is completely at odds with fundamental principles of primary care interactions. If primary care physicians focused on the numbers first, they would end up imposing their own priorities onto patients, rather than letting patients help set the agenda. Consider a visit with a depressed patient or one with chronic pain. Until a physician addresses such issues, there is little chance of managing chronic conditions well. Kerr and colleagues clearly show that competing demands are a major predictor of provider response to elevated blood pressure.(2) The open- ended nature of initial contact helps us to prioritize care and is essential for establishing patient rapport and trust. A subspecialist in hypertension or endocrinology might arguably be justified in addressing the numbers and pushing off other patient concerns. But no plausible argument can be made that primary care physicians treat the numbers, not the patient.

References:

1. Phillips L, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med 2008; 148: 783-5.

2. Kerr EA, Zikmund-Fisher B, Klamerus M et al. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med 2008; 148: 728-736.

3. Vijan S, Hawyard RA. Treatment of hypertension in type 2 diabetes: Blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Internal Med. 2003; 138: 593-602.

4. Messerli FH, Mancia G, Conti CR et al. Dogma disputed: Can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006; 144: 884-893.

5. Glasziou P, Irwig L, Hertier S, et al. Monitoring cholesterol levels: measurement error or true change? Ann Intern Med 2008; 148: 656-61.

Conflict of Interest:

None declared

The Cornerstone of Patient-centered care
Posted on June 20, 2008
Cynthia M. Boyd
Johns Hopkins University
Conflict of Interest: None Declared

To the Editor:

RE: It's Time to Overcome Clinical Inertia, Editorial, 20 May 2008

We read with appreciation the innovative paper by Kerr et. al.(1) However, the accompanying editorial by Phillips and Twombly is based solely in the "index condition" framework, where one condition is viewed to be of paramount interest.(2) The editorialists argue that blood pressure is the "most" important condition not well treated. Surely, this valuation depends on the defining perspective, whether it be the public health, cost, or the health of an individual patient. We suggest that this is the wrong way in which to frame the issue as it fails to adequately acknowledge a patient-centered perspective of chronic illness care, in which all the conditions a patient has are considered, in terms of the relative benefit of treating each condition in the presence of their other conditions, the cumulative effect of all the recommended treatments, and the individual's treatment priorities.(3,4)

Their treatment paradigm is similarly flawed.(2) Treating "every occurrence" of elevated blood pressure will, for some patients, threaten important outcomes such as functional capacity, quality of life, continence, and psychological well being. Adding a new medication or increasing medication dose is a major clinical decision, as doing so potentially reduces adherence to other medications, increases risk of side effects, adds to treatment burden or caregiver burdens, and increases costs. Thus, before augmenting therapy, it would be prudent to explore adherence, self-management strategies, issues related to treatment burden and patient preferences, and to engage patients to identify their treatment goals for all their conditions. Assuming that all patients want to talk about their "numbers first" violates the principles of patient- centered care. Finally, the paradigm doesn't acknowledge relative attributable benefit within one condition or consider all the conditions a person has.(4) That is, achieving a reduction in systolic blood pressure from 160 to 140 is likely to produce a greater benefit in hypertension specific outcomes compared with achieving a reduction from 133 to 128. In the latter case, it may be more important to discuss anticoagulation for atrial fibrillation, treatment of depression, or a family issue.

Defining "clinical inertia," as a "failure" is a pejorative construct. On the one hand, it may be that physicians are not treating an important problem as effectively as possible. Alternatively, physicians may be providing patient-centered care, accounting for patients' individual situations and multimorbidity.(5) Rather than enforcing nearly absolute rules, new paradigms should be developed to understand these issues in greater depth.

1. Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717- 727.

2. Phillips LS, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med. 2008 May 20;148(10):783-5.

3. Boyd CM, Darer JD, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. 2005 Aug 10;294(6): 716-24.

4. Kent DM, Alsheikh-Ali A, Hayward RA. Competing risk and heterogeneity of treatment effect in clinical trials. Trials. 2008 May 22;9:30.

5. Weiss CO, Boyd CM, Wolff J, Yu Q, Leff B. Patterns of prevalent major chronic disease among older adults in the United States. JAMA. 2007 Sep 12;298(10):1160-2.

Conflict of Interest:

None declared

Re: Clinical inertia or just following guidelines?
Posted on June 26, 2008
Sam F Carter
Murfreesboro Medical Clinic
Conflict of Interest: None Declared

Since sending my Rapid Response on May 27, I have now learned of a joint scientific statement (published online May 22 ahead of print) recommending routine home monitoring for the majority of patients with hypertension and use of those results to guide therapy (1).

1. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52:1-9.

Conflict of Interest:

None declared

It's Time to Overcome Clinical Inertia
Posted on July 10, 2008
Marshall Silverman
Presbyterian Hospital, Charlotte, NC
Conflict of Interest: None Declared

Treating diabetic hypertension in today's busy office practice is often a losing proposition (1). Time constraints, competing patient demands (2), patient noncompliance (3), and clinical uncertainty (4) can all impede our patients' progress toward optimal blood pressure control. In their editorial, "It's Time to Overcome Clinical Inertia", Phillips and Twombly cite clinical uncertainty and subsequent inertia on the part of the physician as the root of the problem. They suggest a paradigm shift in the management of diabetic hypertension: ". . . once hypertension is diagnosed, every occurrence of blood pressure above goal should prompt intensification of therapy unless contraindicated by problems, such as hypotension. " In order to put this paradigm into practice, clinicians should "'run the numbers' first and deal with blood pressure and glucose before asking about other problems (5)."

There are inherent problems with this approach. First, there are multiple causes for isolated elevations in blood pressure. Diabetics, like everyone else, sprain their ankles, catch colds, rush to their appointments, and drink their morning coffee. Pain, over-the-counter medications such as decongestants, physical activity and caffeine can all transiently raise blood pressure (6-8). If we don't take the time to first discuss these "comorbid conditions" - which are often the primary reason for the visit - then we risk overtreating our patients. Even if our patients tolerate intensification in therapy when they may not need it, there is the extra financial burden, the possibility of medication interaction, as well as the concern over noncompliance that accompanies an escalating pill count.

White Coat Syndrome is another entity that affects physician's confidence and ability to treat hypertension. In the last few years, however, the availability of accurate and inexpensive automatic sphygmomanometers has all but erased this source of uncertainty. Numerous studies have established their accuracy in the ambulatory setting (9-11). It is relatively simple for patients to check their blood pressures two or three days per week, record their readings and fax, mail, email, or bring their blood pressure log to their doctor. Patients can bring their monitors to their next office visit, regardless of the reason for that visit, in order to insure that the home monitor correlates closely with the office sphygmomanometer. Once confirmed, medication adjustment can be made based on the patients' blood pressure log with very little uncertainty and without cutting into the office time needed to address the patients' other complaints. Everybody wins.

References 1. Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care. 2003;26:355-9 2. Parchman, ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med. 2007;5:196-201. 3. Grant R, Adams AS, Trinacty CM, Zhang F, Kleinman K, Soumerai SB, et al. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care. 2007;30:807-12. 4. Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717-27 5. Phllips LS, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med. 2008;148:783-4. 6. Reeves RA. Does this patient have hypertension? JAMA 1995;273:1211- 18. 7. Lake CR, Gallant S, Masson E, Miller P. Adverse drig effects attributed to phenylpropanolamine: a review of 142 case reports. Am J Med 1990;89:195 -208. 8. Jee SH, He J, Whelton PK, et al. The effect of chronic coffee drinking on blood pressue. Hypertension 1999;33:647-52. 9. Kleinert HD, Harshfield GA, Pickering TG, et al. What is the value of home blood pressure measurement in patients with mild hypertension? Hypertension 1984 Jul-Aug;6(4):574-8. 10. Verberk WJ, Kroon AA, Kessels AG, de Leeuw PW. Home Blood Pressure Measurement A Systematic Review. J Am Coll Cardiol 2005 Sep 6;46(5):743- 751. 11. Asayama K, Ohkubo T, Kikuya M, et al. Prediction of stroke by self- measurement of blood pressure at home versus casual screening blood pressure measurement in relation to the Joint National Committee 7 classification: the Ohasama study. Stroke 2004 Oct;35(10):2356-61.

Conflict of Interest:

None declared

It's Time to Overcome Clinical Inertia - Reply to Letters
Posted on July 12, 2008
Lawrence S. Phillips
Emory University School of Medicine
Conflict of Interest: None Declared

We thank the responders to our editorial for their thoughtful concerns, but we believe that hypertension management needs to improve, and we address the issues they raise.

While clinical inertia can be a pejorative term, acknowledging our own deficiencies (1) was a key first step in improving our care (2). Requiring that every detail of recommendations for care be based on evidence from clinical trials can lead to "evidence-based paralysis" (3) "“ failure to act in the absence of specific trial-based evidence; the <140 mmHg systolic blood pressure (SBP) goal is well supported (4). Although intensification of therapy promotes polypharmacy and risks nonadherence, these are part of the cost of better hypertension management. Fortunately, emphasis by the provider increases adherence (5;6); patients will be more likely to take hypertension medications if we emphasize their importance "“ and if we don't mention blood pressure, patients may conclude that it's not important.

Addressing blood pressure (an "index condition") at the start of visits might seem to go against having visits be patient-centered, but patients might emphasize symptomatic over asymptomatic problems. Finding the best balance is not simple, and it is our responsibility to help patients appreciate the importance of disorders such as hypertension and diabetes. While blood pressure shouldn't dominate, it shouldn't be overlooked; our paradigm should help avoid errors of omission. We also recognize that fluctuations in SBP can be substantial, especially in the elderly and in patients with type 1 diabetes, but variability is usually damped when blood pressure is better controlled. Accordingly, it is reasonable to recommend that blood pressure above goal should always prompt intensification unless there are problems such as orthostasis.

We agree that complications from hypertension are linked more tightly to ambulatory blood pressure than to measurements in the office, but ambulatory pressures aren't always available, and we don't know how best to use them. The risk from office SBP 140 mmHg corresponds to that of a lower average ambulatory pressure (7) or a lower first morning pressure (8), but it isn't clear exactly how low ambulatory pressures must be to be reassuring. Our paradigm responds to office pressure-based guidelines (4), and was designed to be universally applicable.

Our understanding of the basis for clinical inertia has been advanced by the demonstration of contributions from "clinical uncertainty" (9) and "competing demands" (10), but it's been almost seven years since the concept was promulgated (11); we believe that rather than further studies of mechanisms, it's time to focus on overcoming clinical inertia. The management paradigm we offer (12) should help us to move forward.

Reference List

(1) El-Kebbi IM, Ziemer DC, Musey VC, Gallina DL, Bernard AM, Phillips LS. Diabetes in urban African-Americans. IX. Provider adherence to management protocols. Diab Care. 1997;20:698-703.

(2) Ziemer DC, Doyle JP, Barnes CS, Branch WT, Jr., Cook CB, El- Kebbi IM et al. An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8. Arch Intern Med. 2006;166:507-13.

(3) Ziemer DC, Phillips LS. The Dogma of "Tight Control": Beyond the Limits of Evidence"”Reply. Arch Int Med. 2006;166:1672.

(4) Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JLJr et al. The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560-2571.

(5) Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication: patients' response to medical advice. N Engl J Med. 1990;280:535.

(6) Bonds DE, Camacho F, Bell RA, Duren-Winfield VT, Anderson RT, Goff DC. The association of patient trust and self-care among patients with diabetes mellitus. BMC Fam Pract. 2004;5:26.

(7) Sega R, Corrao G, Bombelli M, Beltrame L, Facchetti R, Grassi G et al. Blood pressure variability and organ damage in a general population: results from the PAMELA study (Pressioni Arteriose Monitorate E Loro Associazioni). Hypertension. 2002;39:710-714.

(8) Kamoi K, Miyakoshi M, Soda S, Kaneko S, Nakagawa O. Usefulness of home blood pressure measurement in the morning in type 2 diabetic patients. Diab Care. 2002;25:2223.

(9) Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717-27.

(10) Turner BJ, Hollenbeck CB, Weiner M, Tenconi M-TP, Tang SSK. Do unrelated comorbidities negatively influence hypertension management? Annals Int Med. 2008;148:576-84.

(11) Phillips LS, Branch WT, Jr., Cook CB, Doyle JP, El-Kebbi IM, Gallina DL et al. Clinical inertia. Ann Int Med. 2001;135:825-34.

(12) Phillips LS, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med. 2008;148:783-85.

Conflict of Interest:

None declared

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