Rose AJ (Bedford VAMC, Center for Health Quality, Outcomes, and Economic Research (CHQOER)), Shimada SL
(Bedford VAMC, CHQOER), Rothendler JA
(Bedford VAMC, CHQOER), Reisman JI
(Bedford VAMC, CHQOER), Glassman PA
(Sepulveda VAMC, Center for the Study of Healthcare Provider Behavior), Berlowitz DR
(Bedford VAMC, CHQOER), Kressin NR
(Bedford VAMC, CHQOER)
The failure to manage a chronic condition aggressively enough to bring it under control has been called “clinical inertia”. Clinical inertia has been shown to be a major barrier to achieving control of chronic conditions such as hypertension. Understanding the reasons for clinical inertia could lead to more effective interventions to reduce it.
We studied patients with a diagnosis of hypertension from the primary care clinics of two urban VA Medical Centers. All patients had elevated blood pressure (BP) values that triggered a computerized reminder. The reminder is designed to prompt clinicians to respond to uncontrolled BP or to supply a reason for not intervening. In response to the reminder, clinicians frequently asserted that medication adjustments were unnecessary because the patient’s BP was “usually well-controlled”. We examined all responses to the reminder that related to whether or not the medications were adjusted. Using recent BP values from the electronic medical record (EMR), we assessed the accuracy of this assertion.
The reminder was resolved at least once for a total of 1,580 patients. The most common response to the reminder was to adjust the medications (46%) and the second most common was to assert that the BP was “usually well-controlled” (27%). Among the patients whose clinicians asserted at least once that their BP was “usually well-controlled”, the BP value immediately prior to the one that triggered the reminder was 140/90 mm/Hg or higher 57% of the time. Systolic BP was more likely to be uncontrolled than diastolic, and was 160 mm/Hg or higher 18% of the time. In examining the 3 BP values immediately prior to the trigger BP, 2 of 3 were uncontrolled in 34% of patients, and all 3 were uncontrolled in 26%.
Inaccurate recall or interpretation of recent BP values may contribute to clinical inertia in the treatment of hypertension. Clinicians may be especially likely to overlook poorly-controlled systolic BP.
Our findings can guide the design of interventions to reduce clinical inertia in hypertension care. The VA hypertension reminder may need to provide more detailed information regarding recent BP control.