Therapeutic inertia in hypertension management - status quo in primary care.

Abstract

‘A tendency to do nothing or to remain unchanged’ defines inertia according to the Oxford Dictionary by Lexico. In a medical context, the term ‘clinical inertia’ was introduced by Philipps et al. [1] in 2001, based on their long-standing observations of diabetes care, and relating to the failure of healthcare providers to initiate or intensify therapy appropriately during visits. They identified three major doctor-related factors contributing to this failure, including overestimation of care provided; use of ‘soft’ reasons to avoid intensification of therapy; and lack of education, training and practice organization aimed at achieving therapeutic goals [1]. O’Connor et al. [2] later on suggested three principal origins of therapeutic inertia namely doctor factors, patient factors and office (practice) system factors. Of relevance in the current context is their estimation that the relative percentage of contribution to therapeutic inertia is attributable to doctor factors in at least 50% of cases, whereas patient factors (30%) and practice factors (20%) are overall perhaps less impactful albeit still important. Consequently, identification of the major causes of doctor-related therapeutic inertia paired with appropriate education and support tools to reduce its occurrence may yield tangible benefit for affected patients [3]. Clinicians however may be predisposed not to treat in areas of preventive health and chronic disease because they are, by training and inclination, interested and prepared to problem solve in more acute situations of ill health. Furthermore, the Hippocratic Oath exhorts the doctor to ‘first do no harm’. Unfortunately, insufficient use of available therapies is particularly important in common chronic diseases such as diabetes, hypertension and dyslipidaemia. Indeed, therapeutic inertia related to the management of diabetes, hypertension and lipid disorders combined have been suggested to contribute to up to 80% of heart attacks and strokes [2]. Hypertension clinicians have long recognized that inertia is an important feature of blood pressure management and studies from many different settings and countries have demonstrated the existence of clinical inertia. Amongst other reasons for clinicians not to intensify therapy unwarranted optimism, overconcern about adverse effects, and willingness to further negotiate care have been identified [4]. Furthermore, uncertainty in regards to what a patient’s ‘true’ blood pressure maybe has been suggested as a significant hurdle to intensifying therapy [5]. In the current issue of the journal, Ali et al. [6] present data on therapeutic inertia in the management of hypertension in a primary care setting in which the majority of patients with chronic conditions including hypertension are managed in most countries. The authors used data from a large general practitioner (GP) network in the Netherlands to identify the prevalence of therapeutic inertia and characteristics of relevant patient cohorts were investigated [6]. Therapeutic inertia was evident in a staggering 87% and was similar in men and women. Older age, lower systolic, diastolic and neartarget SBP, and diabetes were positively associated, although renal insufficiency and heart failure were inversely related to inertia. GPs did not intensify therapy because they considered office BP measurements as nonrepresentative (27%), waited for next BP readings (21%) or wanted to optimize lifestyle first (19%). Eleven percent of patients explicitly did not want to change treatment. This is a timely and likely representative survey of the status quo of therapeutic inertia in a European country well respected for its healthcare system. The study highlights an ongoing significant issue with therapeutic inertia in primary care which seems difficult to overcome despite the fact that a wide variety of interventions have been evaluated in clinical trials and that their use has been demonstrated in larger epidemiological studies to overcome clinical inertia with improved blood pressure control via increased use of multiple antihypertensive medications [7]. Journal of Hypertension 2021, 39:1107–1108 Dobney Hypertension Centre, School of Medicine Royal Perth Hospital Unit / Medical Research Foundation, University of Western Australia, Crawley, DepartDepartments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Western Australia and Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia