E d i t o r i a l

Physician or Clinical Inertia:What Is It? Is It Really a Problem?And What Can Be Done About It?

Marvin Moser, MD

There is a perception that physicians are doinga poor job of treating hypertension despite

the availability of effective, well-tolerated ther-apy. We are reminded that only about 35% to40% of patients with elevated blood pressure(BP) have their BP controlled to goal levels andthat only about 60% are receiving antihyperten-sive medication.1 Some of these data may be 4 ormore years out of date. Recent surveys in largegroup practices or national polls note that asmany as 90% of patients appear to be receivingtreatment with some medication and that >50%of the respondents state that their BP is con-trolled to levels below the presently accepted goalof 140 ⁄ 90 mm Hg.2,3 Admittedly, some of thesedata are ‘‘soft,’’ but it is clear that we are doinga better job than some would have us believe;obviously, there is more that we can do. Physi-cian or clinical inertia has been one reason citedto explain less than ideal treatment results.

PHYSICIAN INERTIAPhysician inertia is defined as the failure to initiatetherapy or to intensify or change therapy inpatients with BP values >140 ⁄90 mm Hg, or>130 ⁄80 mm Hg in hypertensive patients with dia-betes, renal, or coronary heart disease. The termclinical or physician inertia has been used todescribe situations in which patients return for

visits having taken their medication but have nothad therapy changed despite BP levels that arehigher than levels established by guidelines.4 It hasalso been applied with regard to the large numberof patients (usually older than 60 years) withsystolic hypertension for whom physicians arereluctant to provide any specific treatment. Aboutone-third of patients whose BP values are consis-tently above goal levels do not have medicationstarted, changed, or increased.2,5,6 In patients withcomorbid conditions, about 50% do not have treat-ment changed despite persistently elevated BP, anddespite guidelines that physicians claim to accept,many physicians do not attempt to treat elevatedsystolic BP until it is >150 mm Hg.7,8 Thesepatients, as noted, compose a majority of thepeople included in the ‘‘not at goal’’ group.

Patient adherence to therapy is another majorproblem, but first it may be of interest to reviewthe results of therapy even when BP was notreduced to the goal levels that have been used todefine adherence.

RESULTS OF TREATMENT WITHOUTACHIEVING ‘‘GOAL’’ BP INMANY PATIENTSIt is self-evident that lowering BP is effective inreducing morbidity ⁄mortality not just from cerebro-vascular but also from cardiovascular events.9,10

Treatment of hypertension in the United States hasresulted in dramatic decreases in morbidity ⁄mortal-ity—a decrease greater than noted in other industri-alized countries. It is important to remind ourselvesthat strokes and stroke deaths have been reducedby >60% since the 1970s when the National High

From the Yale University School of MedicineAddress for correspondence: Marvin Moser, MD,13 Murray Hill Road, Scarsdale, NY 10583E-mail: moserbp@aol.com

doi: 10.1111/j.1751-7176.2008.00047.x

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Blood Pressure Education Program began. A largepart of this decrease is attributable to better treat-ment of hypertension. Rates of congestive heartfailure from hypertension have decreased by>50%; progression from less severe to more severehypertension as well as coronary events and pro-gression of renal disease have also decreaseddramatically.9,10 There is nothing new about thesedata.

Lowering BP to the presently recommendedguidelines of <140 ⁄90 mm Hg in those withuncomplicated hypertension or to <130 ⁄80 mmHg in patients with diabetes, renal disease, or coro-nary heart disease has become the objective of clini-cal trials and national efforts.11 These are arbitrarylevels but have been established as cut points todefine treatment goals. Clinical trials in which spe-cific protocols are followed, with free medication, agreat deal of ancillary help, and systematic follow-ups, have reported that diastolic BP values can bereduced to <90 mm Hg in >90% of patients butthat only about 60% have their systolic BP valuesreduced to <140 mm Hg.12 These results havebeen widely publicized and used as examples ofwhat can be accomplished with a goal-orientedapproach. At present, these goals are not beingachieved in many clinical settings. But in many tri-als in which benefits have been reported, BP valueshave not been lowered to <140 ⁄90 mm Hg in alarge number of patients.13–15

WHICH PATIENTS ARE NOTEXPERIENCING BP CONTROL?The large majority of patients who do not experi-ence the recommended reduction in BP to goallevels are elderly (ie, older than 60). Most have iso-lated systolic hypertension, defined most recently asBP values >140 ⁄<90 mm Hg. It is clear that mostinstances of reported poor control rates relate topoor control of systolic BP.

CAUSES OF POOR PHYSICIAN ANDPATIENT ADHERENCE TO THERAPYAre physician or clinical inertia and ⁄or poor patientadherence to therapy the major causes of the prob-lem in most cases of poor BP control? Are theresome patients whose BP cannot be reduced andcontrolled to goal levels despite adequate care andadherence to a treatment regimen?16 For years,patient adherence or compliance was advanced as amajor cause for the lack of better treatment results:patients’ failure to return for visits, patients’ failureto fill prescriptions because of cost concerns,patients’ lack of awareness of the significance of

elevated BP or its complications, or patients justforgetting. When asked why a higher percentage ofpatients do not have BP controlled, many physi-cians repeat these patient-related factors. In recentyears, however, numerous investigators have sug-gested that barriers to the effective management ofuncontrolled hypertension also include many physi-cian-related problems: lack of concern for higherthan ideal but ‘‘not very high’’ pressures; complex-ity of prescribing or monitoring drug regimens;physician practice patterns; lack of physician-patient rapport or trust; failure to communicate theimportance of continuing therapy; lack of ongoingattention to asymptomatic diseases such as hyper-tension in patients with symptomatic comorbiditiessuch as arthritis, diabetes, or pulmonary disease;and concern about drug adverse effects. Some ofthese issues can actually be addressed within thecontext of the time constraints of managed care.

PATIENT EDUCATIONOne of the ways to reduce physician inertia is toimprove the patients’ understanding of why it isimportant to treat hypertension effectively.17 Wehave long been critical of the fact that much lip ser-vice but not much effort is given to patient educa-tion.18 In the present world of managed care andlimitations of physicians’ time with patients, it ismore important than ever that educational materi-als be made available to patients. For many years,the National High Blood Pressure Education Pro-gram distributed booklets on hypertension forpatients; there are also many educational materialson hypertension available from the American HeartAssociation and other organizations such as theHypertension Education Foundation (hypertension-foundation.org). These are not being used. Lookaround your own office or check the offices ofother internists, family physicians, or cardiologists.It is rare to find any material about hypertension inthe waiting or treatment rooms. Contrast this tothe offices of nose and throat physicians, ortho-pedists, or dentists, where relevant materials arereadily available. One of the first things that mustbe done to improve patient adherence and indi-rectly to reduce clinical inertia is to provide moreup-to-date educational material and to make thepatient proactive in understanding the reasons fortherapy and insisting on changes in therapy if BP isnot at goal levels. This will not solve the problemof inertia, but it will help.

In addition, physicians must be more active inconveying the message that treatment of hyperten-sion is necessary and highly effective in reducing

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disease. Yes, there are time constraints, but the mes-sage should be that (1) elevated BP may exist with-out symptoms and should be treated; (2) treatmentis generally lifelong; (3) lifestyle changes that areadvocated might work in some cases of less severehypertension, but in most cases medication is neces-sary; (4) 1 medication may not be effective (2 or 3may be necessary); (5) if BP values are reduced tonormal, medication should not be stopped; andfinally (6) if medication is taken as prescribed andBP values are reduced, many of the complications,like stroke and heart failure, will be prevented.

Many years ago, we tested the time it took todeliver this type of message. It can be accomplishedin less than 2 to 3 minutes. It should be part of thephysician’s responsibility to keep the patientinformed. In turn, an informed patient will serve asa reminder to the provider to treat hypertensionmore effectively.

AT WHAT BP LEVEL SHOULD TREATMENTBE STARTED, ESPECIALLY INTHE ELDERLY?As noted, studies have suggested that many physi-cians do not begin specific treatment unless thesystolic BP is >150 mm Hg despite good epidemio-logic evidence that morbidity ⁄mortality areincreased at these levels when compared to systolicBP values <140 mm Hg.14 They are reluctant totreat older patients who feel well, especially whenthey are older than 75 to 80, despite data that low-ering systolic BP in this population will reducestrokes, heart failure, and coronary heart diseaseevents.15 Concern for adverse effects, especiallyhypotension or weakness, is also a factor in theelderly population. In our experience, however, andin the clinical trials, these were not majorconcerns—if BP is lowered gradually and moni-tored in the upright position. The higher BP levelsthat some physicians use as criteria for beginningtherapy may explain a great deal of physicianinertia.

One might argue that in the trials, such asthe Systolic Hypertension in the Elderly (SHEP),13

the European Systolic Elderly (Syst-Eur) Trial,14

or the Hypertension in the Very Eldery Trial(HYVET),15 systolic BP was not reduced (on aver-age) to <140 mm Hg and that a reduction of only12 to 15 mm Hg reduced events: any lowering ofBP is beneficial.

Why are guidelines insisting on a value<140 mm Hg as a goal without definitive data inthis population? In the opinion of many experts,these guidelines—even if not yet proven in clinical

trials—are reasonable based on good epidemiologicdata and experience.

Some inertia is also the result of confusion as towhich BP measure to use. Data suggest that somephysicians are confused: should clinic or home BPreadings be used for treatment decisions?14 Shouldambulatory BP monitoring be performed to get the‘‘true’’ BP? While data do suggest that home andambulatory BP values may be somewhat better pre-dictors of risk, we should remember that in all thetrials, including studies in the elderly, clinic BPreadings were used to determine outcome: thehigher the ‘‘on-treatment’’ BP, the worse the out-come. BP was assessed just 4 to 6 times a year, andthe values obtained were good predictors. Whilehome BP values are useful for patient adherenceand do provide some guidance regarding between-visit BP levels, clinic BP readings should, I believe,continue to be used to determine the initiation oftherapy and changes in treatment, unless there is adisconnect between BP values and patients’ symp-toms, for example, headaches or dizziness at homewith normal office BP values. Home BP readingswill help to determine whether BP values are higheror lower than in the office and to adjust treatmentaccordingly. This approach should help to removethe ‘‘confusion’’ aspect of the inertia question.While some experts may contend that we may betreating some white-coat hypertension unnecessar-ily, persistently elevated office or clinic systolic BPvalues in the elderly most commonly suggestpathology and should be lowered.

Finally, the presence of comorbidities appearto influence physician behavior. If a patient isbeing treated for painful arthritis, emphysema,asthma, or diabetes, their relatively asymptomatichypertension may be ignored; a simple remedyfor this problem is assessing BP routinely at officevisits. If values are normal (<130 ⁄80 mm Hg) onseveral occasions over a 3- to 6-month period,then a 1-year interval is probably adequate. If BPvalues are >140 ⁄90 mm Hg, they should betreated.

Physician or clinical inertia can be reduced if theabove recommendations are followed. It clearly is aproblem but one that can be overcome to a greatdegree.

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