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Zikmund-Fisher BJ, Hofer TP, Klamerus ML, Kerr EA. First Things First: Difficulty with Current Medications Is Associated With Patient Willingness to Add New Ones. The patient. 2009 Dec 1; 2(4):221-231.
BACKGROUND: Inadequate blood pressure (BP) control remains prevalent. One proposed explanation is "clinical inertia," often defined as the failure by providers to initiate or intensify medication therapy when otherwise appropriate. However, patients could contribute to clinical inertia by signaling an unwillingness to consider medication intensification. OBJECTIVE: To explore covariates of patient attitudes regarding medication intensification. STUDY DESIGN: Cross-sectional survey. SETTING: 9 Midwestern U. S. Veterans' Administration medical facilities. PARTICIPANTS: 1,062 diabetics identified as having BP > = 140/90 mm Hg as part of a prospective cohort study of clinical inertia in hypertension treatment. MEASUREMENTS: Primary outcome was participants' indicated willingness to intensify BP medications if their provider noted elevated BP levels. Potential covariates assessed included BP control (actual and perceived), perceived importance of BP control, BP management self-efficacy, competing demands, medication factors (adherence and management issues), trust in provider, and sociodemographic factors. RESULTS: While 64% of participants reported complete willingness to intensify BP medications, 36% of participants expressed at least some unwillingness. In ordered logistic regression analysis, willingness to intensify was negatively associated with medication concerns, particularly concern about side effects (OR = 0.49, 95% CI: 0.42, 0.59) and adherence or management problems (OR = 0.72, 95% CI: 0.57, 0.91), and positively associated with perceived dependence of health on BP medications (OR = 1.50, 95% CI: 1.26, 1.79) and trust in provider (OR = 1.30, 95% CI: 1.10, 1.54). Importance of BP control had a weaker, non-significant association with willingness to intensify as well (OR = 1.17, 95% CI: 0.99, 1.40). Neither competing demands, current BP control, current number of medications prescribed, nor self-efficacy was associated with willingness to intensify medications. CONCLUSIONS: Patients' willingness to consider intensification of BP medications appears primarily determined by how well patients are managing their current medications, rather than patients' perceived importance of BP control, their self-efficacy, or their prioritization of BP control versus other health demands. Greater attention to patients' pre-existing medication issues may improve providers' ability to intensify BP medication therapy when medically appropriate while simultaneously improving patient satisfaction with care.