Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3049 — Prevalence and Causes of Apparent Clinical Inertia among Patients with Diabetes and Hypertension

Kerr EA (Ann Arbor COE and QUERI-DM) , Zikmund-Fisher B (Ann Arbor COE), Klamerus M (Ann Arbor COE), Subramanian U (Indianapolis COE), Hofer TP (Ann Arbor COE and QUERI-DM)

Objectives:
Clinical inertia, the failure to initiate or intensify therapy in the face of apparent need, has been proposed as a main contributor of suboptimal blood pressure (BP) control. Little is known, however, about the causes of apparent clinical inertia, nor how competing demands such as patient comorbidities affect inertia. We examined causes for the failure to intensify BP medications among hypertensive diabetic patients and the role of competing demands on apparent clinical inertia.

Methods:
We enrolled 1175 diabetic patients of 92 primary care providers (PCPs) in nine Midwest VA facilities. Patients were enrolled if their triage BP prior to their PCP visit was >=140/90. After the visit, PCPs were asked whether they intensified BP therapy and provided reasons for not intensifying. PCPs also listed the conditions or issues they spent the most time on during the visit. PCPs returned this post-visit survey for 1164 patients. We classified conditions that were unrelated to diabetes and hypertension as discordant (e.g., asthma, chronic pain, preventive care) and other conditions as concordant (e.g., coronary disease, renal failure). Using bivariate statistics, we examined the association between discordant and concordant competing demands and BP medication intensification.

Results:
637 (55%) patients with elevated BP at triage did not receive BP medication intensification. The most common reasons reported for not intensifying medications were: 1) PCP obtained a repeat acceptable BP (26%); 2) patient did not take medications prior to visit (20%); 3) BP is usually in good control (18%); 4) home BPs are lower (18%); 5) patient’s adherence can be improved (16%); and 6) BP is close to good control (12%). Excluding patients with lower acceptable BPs, patients were less likely to receive intensification when at least one discordant competing demand was present (48% vs. 56%, p=0.01) and much less likely to receive intensification when 2 or more were present (40% vs. 53%, p=0.009).

Implications:
Uncertainty around true BP measurement values and patient adherence issues were common reasons for clinical inertia. Presence of discordant competing demands decreased the probability of intensification.

Impacts:
Understanding the prevalence of true clinical inertia and its root causes can help us to develop effective policies to improve quality of care.