1017 — Lack of Treatment Intensification in a Trial of Home Telemonitoring and Medication Management: Clinical Inertia or Good Clinical Judgment?
Crowley MJ (Center for Health Services Research in Primary Care, Durham VAMC), Danus S
(Center for Health Services Research in Primary Care, Durham VAMC), Oddone EZ
(Center for Health Services Research in Primary Care, Durham VAMC), Bosworth HB
(Center for Health Services Research in Primary Care, Durham VAMC), Powers BJ
(Center for Health Services Research in Primary Care, Durham VAMC)
Clinical inertia represents a barrier to controlling blood pressure (BP). We evaluated a telemedicine intervention designed to overcome clinical inertia, examined episodes where physicians did not intensify treatment for elevated BP, and sought to determine reasons for treatment non-intensification.
The Hypertension Intervention Nurse Telemedicine Study (HINTS) utilized home BP telemonitoring, physician medication management, and decision support software (DSS). When a subject’s 2-week mean home BP was above goal ( > 135/80 for patients with diabetes, > 135/85 for others), an alert was triggered for physican review and possible medication intensification. We analyzed alert episodes for medication recommendations, agreement between physicians and DSS, and reasons for physician inaction.
The 296 subjects receiving home telemonitoring and medication management generated 1216 alert episodes. After telephone contact, nurses perceived subjects as adherent in 922 episodes (75.9%), and therefore eligible for medication intensification. Physicians recommended intensification in 374 of these 922 episodes (40.6%). When changes were recommended, physician and DSS agreed in 221 episodes (59.1%) and disagreed in 50 (13.4%); in 103 (27.5%), DSS did not make a recommendation (reasons included > = 4 antihypertensives, Cr > 2.5, and technical problems). Among the 548 eligible episodes (59.4%) where physicians did not recommend changes, justifications included perceived acceptable BP (53.7%), recent medication changes outside study (20.6%), and study enrollment too recent (12.8%). For episodes where “BP acceptable” justified non-intensification, the mean SBP was 133.4 (SD 6.8) and DBP 78.4 (SD 9.0). For the 374 episodes where changes were recommended, successful implementation occurred in 294 (78.6%); reasons for non-implementation included receipt of new information that changed the recommendation (47.5%) and patient refusal (37.5%). Patient adherence 4 weeks after successfully implemented changes was 89.5%.
Even with frequent BP measurement, no competing demands, clear treatment goals, DSS, and close follow-up, elevated blood pressures frequently did not result in medication intensification. Perceived acceptable BP and medication changes outside the study were common reasons for inaction. Further work is needed to determine when treatment non-intensification represents good clinical judgment or clinical inertia.
Telemedicine interventions designed to promote aggressive treatment intensification by removing contributors to clinical inertia may not promote high rates of medication intensification.