What is Clinical Inertia The Quandary of Improving Hypertension

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What is Clinical Inertia?The Quandary of
Improving Hypertension
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Case

• 65yo male with diabetes present for f/u
• c/o of dysuria polyuria
• Gabapentin not help diabetic PN
• Glucometer reading ABG 192
• Medicare Part D covers Actos with 50 copay
• Patient on 10 meds
• Triage BP 162/92
• 20 minute visit
• Never had colonoscopy

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What Are The Barriers to Hypertension Management
in this Patient?
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Background

• Clinical inertia missed opportunities to
  improve BP management
• 72 of 498 British patients w/o diabetes
  suboptimal BP control despite 91 med adherence
• 61 of 492 had suboptimal control at 2 successive
  visits
• No treatment intensification in 45
• No intensification in 36 at successive visits

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Methods

• Objective Examine process of care for diabetics
  with triage BP (140/90)
• Setting 9 VA clinics in 3 states
• Questions
• What percent had Rx change at single visit
• What patient/provider factors predict change

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Results

• 49 (573 of 1169) had Rx change
• 511 had new med or dose increase
• 62 had no change but 4 wk f/u plan
• No difference in Rx with age, education, race,
  provider age.

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Patient Characteristics
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Providers

• 92 total 64 MDs, 7 PAs, 21 NPs
• Mean 11.4 years practice (1-33)
• Mean age 48 (31-71)

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Relationship of systolic and diastolic blood
pressures at enrollment and mean previous year
systolic blood pressure with probability of
treatment change
Kerr, E. A. et. al. Ann Intern Med
2008148717-727
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Predictors Rx ?
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Competing Demands Priorities
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Medication Issues
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Organizational Factors
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Limitations

• Unable to assess real world financial barriers to
  change in VA setting
• Homogeneous population

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The Difficulty of Improving BP Outcomes
N3845
Beckett N et al. N Engl J Med 20083581887-1898
After mean f/u of 1.8 years, 48 of patient in
intervention Achieved goal BP of 140/90)