It's Time to Overcome Clinical Inertia
Authors: Lawrence S. Phillips, Jennifer G. Twombly
Journal: Annals of Internal Medicine (2008)

Editorials20 May 2008It's Time to Overcome Clinical InertiaLawrence S. Phillips, MD and Jennifer G. Twombly, MD, PhDLawrence S. Phillips, MDFrom Emory University, Atlanta, GA 30322. and Jennifer G. Twombly, MD, PhDFrom Emory University, Atlanta, GA 30322.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-10-200805200-00011 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail 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 ...References1. CDC Diabetes Cost-effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA. 2002;287:2542-51. [PMID: 12020335] CrossrefMedlineGoogle Scholar2. Grant RW, Cagliero E, Dubey AK, Gildesgame C, Chueh HC, Barry MJ, et al. Clinical inertia in the management of Type 2 diabetes metabolic risk factors. Diabet Med. 2004;21:150-5. [PMID: 14984450] CrossrefMedlineGoogle Scholar3. 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. [PMID: 12547862] CrossrefMedlineGoogle Scholar4. Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, et al. Clinical inertia. Ann Intern Med. 2001;135:825-34. [PMID: 11694107] LinkGoogle Scholar5. de Grauw WJ, van Gerwen WH, van de Lisdonk EH, van den Hoogen HJ, van den Bosch WJ, van Weel C. Outcomes of audit-enhanced monitoring of patients with type 2 diabetes. J Fam Pract. 2002;51:459-64. [PMID: 12019056] MedlineGoogle Scholar6. Arday DR, Fleming BB, Keller DK, Pendergrass PW, Vaughn RJ, Turpin JM, et al. Variation in diabetes care among states: do patient characteristics matter? Diabetes Care. 2002;25:2230-7. [PMID: 12453966] CrossrefMedlineGoogle Scholar7. 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. [PMID: 17259469] CrossrefMedlineGoogle Scholar8. Oliveria SA, Lapuerta P, McCarthy BD, L'Italien GJ, Berlowitz DR, Asch SM. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med. 2002;162:413-20. [PMID: 11863473] CrossrefMedlineGoogle Scholar9. 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. [PMID: 17548846] CrossrefMedlineGoogle Scholar10. 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. LinkGoogle Scholar11. Turner BJ, Hollenbeak CS, Weiner M, Ten Have T, Tang SS. Effect of unrelated comorbid conditions on hypertension management. Ann Intern Med. 2008;148:578-86. [PMID: 18413619] LinkGoogle Scholar12. Kerr EA, Krein SL, Vijan S, Hofer TP, Hayward RA. Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures. Am J Manag Care. 2001;7:1033-43. [PMID: 11725807] MedlineGoogle Scholar13. Vasan RS, Sullivan LM, Wilson PW, Sempos CT, Sundström J, Kannel WB, et al. Relative importance of borderline and elevated levels of coronary heart disease risk factors. Ann Intern Med. 2005;142:393-402. [PMID: 15767617] LinkGoogle Scholar14. Vasan RS, Larson MG, Leip EP, Evans JC, O'Donnell CJ, Kannel WB, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345:1291-7. [PMID: 11794147] CrossrefMedlineGoogle Scholar15. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72. [PMID: 12748199] CrossrefMedlineGoogle Scholar16. Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Hypertension. 2007;49:69-75. [PMID: 17159087] CrossrefMedlineGoogle Scholar17. Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski VL, Egan BM. Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals. Hypertension. 2006;47:345-51. [PMID: 16432045] CrossrefMedlineGoogle Scholar18. Phillips LS, Ziemer DC, Doyle JP, Barnes CS, Kolm P, Branch WT, et al. An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7. Diabetes Care. 2005;28:2352-60. [PMID: 16186262] CrossrefMedlineGoogle Scholar19. Barnes CS, Ziemer DC, Miller CD, Doyle JP, Watkins C, Cook CB, et al. Little time for diabetes management in the primary care setting. Diabetes Educ. 2004;30:126-35. [PMID: 14999900] CrossrefMedlineGoogle Scholar20. Kerr EA, Smith DM, Hogan MM, Hofer TP, Krein SL, Bermann M, et al. Building a better quality measure: are some patients with 'poor quality' actually getting good care? Med Care. 2003;41:1173-82. [PMID: 14515113] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAuthors: Lawrence S. Phillips, MD; Jennifer G. Twombly, MD, PhDAffiliations: From Emory University, Atlanta, GA 30322.Disclosures: None disclosed.Corresponding Author: 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. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Role of Clinical Uncertainty in Treatment Decisions for Diabetic Patients with Uncontrolled Blood Pressure Eve A. Kerr , Brian J. Zikmund-Fisher , Mandi L. Klamerus , Usha Subramanian , Mary M. Hogan , and Timothy P. Hofer Will Running the Numbers First Violate the Principles of Patient-Centered Care? Cynthia M. Boyd and Bruce Leff Will Running the Numbers First Violate the Principles of Patient-Centered Care? Sandeep Vijan , Rodney A. Hayward , and Peter Ubel Will Running the Numbers First Violate the Principles of Patient-Centered Care? Robert C. Sherrick Will Running the Numbers First Violate the Principles of Patient-Centered Care? Lawrence S. Phillips and Jennifer G. Twombly Metrics Cited byComparación de Inercia Terapéutica en Diabetes Mellitus Tipo 2 entre Médicos de Atención Primaria y Endocrinólogos. Una Revisión de la Literatura.Modelling factors associated with therapeutic inertia in hypertensive patients: Analysis using repeated data from a hospital registry in West AfricaAnalysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical TrialSymptom-related patient-provider communication among women with breast cancer receiving chemotherapyCapitulo 6 - Nas trilhas do cuidado à obesidade: quais os caminhos e os sujeitos que orientam percursos?Are the recommendations for post-operative antibiotics in patients with grade I or II acute calculous cholecystitis being applied in clinical practice?Assessing disease severity in bio-naïve patients with RA on treatment with csDMARDs: insights from the Corrona RegistryBlood pressure control practice and determinants among ambulatory hypertensive patients attending primary health care facilities in Addis AbabaSymptom Care at HomeConsensus study to define appropriate inaction and inappropriate inertia in the management of patients with hypertension in primary careExamination of Patient-Reported Outcomes in Association with TNF-Inhibitor Treatment Response: Results from a US Observational Cohort StudyThe Impact of Antihypertensive Drugs on AdherenceAssessing Pain and Unmet Need in Patients with Advanced Dementia: The Role of the Serial Trial Intervention (STI)Decalogue of the Spanish Society of Arteriosclerosis to reduce therapeutic inertiaDecálogo de la Sociedad Española de Arteriosclerosis para disminuir la inercia terapéuticaAutomated home monitoring and management of patient-reported symptoms during chemotherapy: results of the symptom care at home RCTDifferentiation of Diabetes by Pathophysiology, Natural History, and PrognosisClinical characteristics of type 2 diabetic patients on basal insulin therapy with adequate fasting glucose control who do not achieve HbA1c targetsReasons for non-intensification of treatment in people with type 2 diabetes receiving oral monotherapy: Outcomes from the prospective DIAttitude studyIdentifying factors associated with concordance with the American College of Rheumatology rheumatoid arthritis treatment recommendationsGeneral practitioners' justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typologyWhy Is Medication Use Less than Appropriate?Feasibility Testing of a Protocol to Stop Ineffective Drug and Nondrug TreatmentsMedication Routines and Adherence Among Hypertensive African AmericansTranslating What WorksBarriers to improved dyslipidemia control: Delphi survey of a multidisciplinary panelDoes pharmacologic treatment in patients with established coronary artery disease and diabetes fulfil guideline recommended targets? A report from the EUROASPIRE III cross-sectional studyDeterminants and Explanatory Models of Clinical InertiaDoctors' Clinical Inertia as MyopiaAppropriateness of clopidogrel use according to current recommendationsThe concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic reviewClinically relevant quality measures for risk factor control in primary care: a retrospective cohort studyWe Can Change the Natural History of Type 2 DiabetesTotal and low-density lipoprotein cholesterol in high-risk patients treated with atorvastatin monotherapy in the United Kingdom: analysis of a primary-care databaseInterventions to Reduce Clinical Inertia in Cardiac Risk Factor Management in Renal Transplant RecipientsNon-compliance and inertia in hypertensive Spaniards at high cardiovascular risk: CUMPLE studyClinical Inertia in Poorly Controlled Elderly Hypertensive Patients: A Cross-Sectional Study in Spanish Physicians to Ascertain Reasons for Not Intensifying TreatmentHow can resistant hypertension be identified and prevented?Association Between Performance Measures and Glycemic Control Among Patients With Diabetes in a Community-wide Primary Care CohortHypertension TherapyEthical issues in the neurology of aging and cognitive declineInercia terapéutica. Causas y solucionesNurse-led Disease Management for Hypertension Control in a Diverse Urban Community: a Randomized TrialImpact of Delaying Blood Pressure Control in Patients with Type 2 Diabetes: Results of a Decision AnalysisClinical Inertia of Discharge Planning among Patients with Poorly Controlled Diabetes MellitusHipertensión arterial y política de salud en Cataluña: de la teoría a la prácticaReducing Clinical Inertia in Hypertension Treatment: A Pragmatic Randomized Controlled TrialPrescribing practices in a US cohort of rheumatoid arthritis patients before and after publication of the American College of Rheumatology treatment recommendationsBetter analyze the determinants of therapeutic inertia to overcome itTherapeutic management of orally treated type 2 diabetic patients, by French general practitioners in 2010: the DIAttitude StudyWhy Has the US Health System Become What It Is?Is There a Predictive Profile for Clinical Inertia in Hypertensive Patients?Improving Blood Pressure Control Among Adults With CKD and Diabetes: Provider-Focused Quality Improvement Using Electronic Health RecordsGuidelines, Inertia, and JudgmentPhysician Perception of Blood Pressure Control and Treatment Behavior in High-Risk Hypertensive Patients: A Cross-Sectional StudyA Longitudinal Study Examining Adherence to Guidelines in Diabetes Care According to Different Definitions of Adequacy and TimelinessEffect of initial combination therapy with sitagliptin, a dipeptidyl peptidase-4 inhibitor, and pioglitazone on glycemic control and measures of β-cell function in patients with type 2 diabetesDefining quality of care in rheumatology: The American College of Rheumatology white paper on quality measurementClinical inertia in management of T2DMPart II, Provider perspectives: should patients be activated to request evidence-based medicine? a qualitative study of the VA project to implement diuretics (VAPID)Quality Improvement Initiative for Rapid Induction of Hypertension Control in Primary CareImproving blood pressure control rates by optimizing combination antihypertensive therapyA STITCH Saves Time and Lowers Blood Pressure¿Qué se ha hecho antes? ¿Qué hacer a partir de ahora para un mejor control de la hipertensión arterial?Engineering and characterization of the long-acting glucagon-like peptide-1 analogue LY2189265, an Fc fusion proteinWhen Tight Blood Pressure Control Is Not for Everyone: A New Model for Performance Measurement in HypertensionOvercoming insulin "resistance": Assisting patients in transitioning to insulin therapyRacial Disparities in Hypertension Control, but Not Treatment IntensificationImproving Adherence to Treatment GuidelinesEfficacy and Safety of Long‐Term Treatment With the Combination of Amlodipine Besylate and Olmesartan Medoxomil in Patients With HypertensionGeneral Principles of Hypertension Management in the ElderlyWill Running the Numbers First Violate the Principles of Patient-Centered Care?Cynthia M. Boyd, MD, MPH and Bruce Leff, MDWill Running the Numbers First Violate the Principles of Patient-Centered Care?Sandeep Vijan, MD, MS, Rodney A. Hayward, MD, and Peter Ubel, MDWill Running the Numbers First Violate the Principles of Patient-Centered Care?Robert C. Sherrick, MDWill Running the Numbers First Violate the Principles of Patient-Centered Care?Sam F. Carter, MDA Practice-Based Trial of Motivational Interviewing and Adherence in Hypertensive African Americans 20 May 2008Volume 148, Issue 10Page: 783-785KeywordsAntihypertensive drug therapyBehaviorBlood pressureCardiovascular therapyEndocrinologyHealth surveysHypertensionRisk managementSystolic pressureTreatment guidelines ePublished: 20 May 2008 Issue Published: 20 May 2008 Copyright & PermissionsCopyright © 2008 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...