Clinical Inertia

Excellence in patient care will always be partly limited by a lag in dissemination of knowledge. After an advance in clinical understanding, translation of this advance into revised guidelines for practice and incorporation of the guidelines leading to upgraded physician behavior may take 5 to 10 years (1, 2). While the explosion of technology can be expected to accelerate dissemination of information, a second, qualitatively different problem is impeding advancement of the standard of care. This second problem is due in part to a major component of traditional medical education and medical practice: the focus on relieving symptoms. Historically, medicine has been driven largely by patient symptoms. However, illness and death in developed countries such as the United States are now due increasingly to disorders in which abnormal values may be the only manifestation of the disease: hypertension, dyslipidemia, and diabetes (36). These disorders may present as acute problems associated with signs and symptoms. Most often, however, complications resulting in patient symptoms occur only after the disease has existed for many years, as is the case with congestive heart failure, coronary artery disease, and foot ulcers. Thus, good management of these important problems demands that clinicians respond to the abnormal values in the absence of patient symptoms, and responses to such problems should be a high priority during clinical encounters. What Is Clinical Inertia? Strong evidence now indicates that therapy for hypertension, dyslipidemia, and diabetes can prevent or delay complications. The goals for management are well defined, effective therapies are widely available, and practice guidelines for each of these diseases have been disseminated extensively. Despite such advances, health care providers often do not initiate or intensify therapy appropriately during visits of patients with these problems. We define such behavior as clinical inertiarecognition of the problem, but failure to act. We distinguish clinical inertia in the management of hypertension, dyslipidemia, and diabetes from problems in management of other disorders in which the patient may be asymptomatic but an underlying cause of the abnormality must be sought (for example, elevated levels of alkaline phosphatase) and disorders in which patient symptoms prompt action by the physician (for example, shortness of breath). For these other disorders, a diagnosis must be established before therapy can be initiated; physicians pursue the diagnosis, treat presumptively, or categorize the problem as not worth treating. In contrast, the presence of hypertension, lipid abnormalities, or hyperglycemia is sufficient to warrant treatment, and most physicians would agree that treatment is beneficial. However, many patients have these abnormalities but are not treated adequately or are not treated at all. What Is the Evidence for Clinical Inertia in the Management of Hypertension, Dyslipidemia, and Diabetes? There are two lines of evidence for clinical inertia as a problem. The first is epidemiologic, and the second is based on analysis of physician behavior during patient visits. Epidemiologic Evidence for Clinical Inertia Good management of patients with hypertension, dyslipidemia, or diabetes involves two steps: 1) recognizing the abnormality and 2) initiating and intensifying treatment until therapeutic goals are reached. Although physicians diagnose and treat many patients with these disorders (7, 8), most patients are treated inadequately. In the United States, a diagnosis is made for approximately 69% of patients with hypertension (9), 47% of patients with elevated cholesterol levels (10), and 65% of patients with diabetes (11). Moreover, pharmacologic therapy is used for approximately 53% of patients with hypertension (9), 17% to 23% of those with elevated cholesterol levels (10, 12, 13), and 73% of those with diagnosed diabetes (14). However, blood pressure control is adequate in only about 45% of patients treated for hypertension (9), low-density lipoprotein (LDL) cholesterol levels are reduced to goals consistent with National Cholesterol Education Program (NCEP) guidelines in only 14% to 38% of patients (15, 16), and hemoglobin A1c values meet the American Diabetes Association goal of less than 7% (0.07) in only 33% of patients treated for diabetes (14). Problems in making a diagnosis and initiating treatment show the need to educate physicians about the importance of the disorders and the benefits of therapy. However, achieving standard-of-care goals in only limited numbers of treated patients must be attributed either to therapeutic ineffectiveness or to clinical inertia. The attainment of treatment targets in clinical trials shows the effectiveness of present therapies for hypertension, elevated LDL cholesterol levels, and diabetesleaving clinical inertia as the presumptive basis for treatment failure in many patients with these disorders. Analysis of Physician Behavior during Patient Visits Many patients diagnosed with and treated for hypertension, elevated LDL cholesterol levels, or diabetes have physician visits in which therapy is not used properly despite failure to achieve targets. Berlowitz and colleagues (17) followed hypertensive men at five Veterans Affairs hospitals in New England for 2 years. Forty percent of the patients had a blood pressure of 160/90 mm Hg despite an average of more than six hypertension-related physician visits per year. Although patients who received more intensive therapy had significantly better blood pressure control, therapy was increased during only 6.7% of patient visits. Persistent high blood pressure could not be attributed to patient nonadherence to therapy but appeared to occur because the managing physician did not intensify therapy. The authors noted that physicians repeatedly delayed making changes in the regimenan example of clinical inertia in blood pressure management. Becker and coworkers (18) conducted a 2-year trial in Baltimore, Maryland, to evaluate care by a nurse trained in lipid management or enhanced primary care in which physicians received recommendations based on national guidelines. Patients reached goal levels of LDL cholesterol largely because of use of pharmacotherapy (this therapy was associated with a sixfold increase in the odds of reaching the goal level). However, at the end of follow-up, only 45% of patients in the nurse group and 17% of those in the enhanced primary care group still received this therapy. Because the patients were at particularly high risk (they each had a sibling who had documented coronary heart disease before 60 years of age), the authors noted that it is surprising that more siblings requiring pharmacotherapy did not receive it (18). The authors also stated that the primary care providers generally failed to apply guidelines in the very high-risk population, even when promptedan example of clinical inertia in lipid management. El-Kebbi and associates (19) examined clinical decision making over a 3-year period in a municipal hospital diabetes clinic in Atlanta, Georgia. Although providers had previously agreed on a common protocol for managing type 2 diabetes, therapy was intensified during only 36% of 1051 visits of patients who met criteria for advancement of therapy. A total of 198 patients with type 2 diabetes had hyperglycemia that persisted despite a 2-month trial of dietary management, had a previous hemoglobin A1c value greater than 9% (0.09), and had a fasting plasma glucose level greater than 11.1 mmol/L (>200 mg/dL) that was measured and reported to providers during their visits. In these patients, pharmacotherapy was intensified in only 50% of visitsan example of clinical inertia in diabetes management. In combination, the epidemiologic analyses and examinations of provider behavior during patient visits demonstrate the presence of clinical inertia. What Causes Clinical Inertia? Unsatisfactory outcomes of chronic medical conditions undoubtedly involve a component of patient nonadherence. Diabetes complications are found more often in patients who adhere poorly to visit scheduling (20), whereas coronary outcomes are improved in adherent patients even if treatment consists only of a placebo (21). Although outcomes may be related to such patient factors as age, years of education, occupation, and literacy (20, 22), it is well recognized that encouragement by physicians (23, 24) and social support systems (2528) can enhance adherence. Moreover, although patients may not recall recommendations and may not adhere to advice on issues of lifestyle change, they are more likely to remember advice about prescribed medications (29). Clinical inertia is a problem of the health care professional and the health care system, and it is separate from patient-related issues of adherence and access to care (30). While patient nonadherence is frequently cited as a barrier to better management (31, 32), patients generally follow medical recommendations in two critical ways: They return for office visits, and they do not decline to take medications as recommended (29, 33), although they may not take every dose of the medications (34). Thus, patient nonadherence cannot explain the failure of providers to initiate or advance therapy appropriately during patient visits. Financial pressures could limit time for patient care, but Chaudhry and colleagues (35) found little evidence that more productive physicians did not deliver preventive services. Concern about cost and side effects of medications may contribute to failure to use pharmacologic therapy when indicated. However, clinical inertia occurs in Veterans Affairs hospitals and public health clinics, where medication costs may be less of a problem (17, 19, 33, 36). In addition, side effects should be less of a concern in patients who are already taking lower doses of the drug (19, 36). It is conceivable that health care