Clinical inertia may represent good clinical judgment in hypertension telemanagement
Clinical inertia, i.e., provider failure to initiate or intensify antihypertensive medication therapy when indicated by clinical guidelines, is a prime contributor to inadequate blood pressure (BP) control. This issue has become increasingly important with the spread of home BP telemonitoring that provides a greater number of readings over longer periods of time than any individual clinic visit. BP telemonitoring allows physicians to better understand patients' usual BP and also provides more opportunities for the physician to intervene by intensifying medications, if indicated.
Using a home telemonitoring approach, what initially looked like clinical inertia may instead have represented good clinical judgment on the part of the study physicians, concluded a new study by a team of researchers from the Durham, NC, Veterans Affairs Medical Center and Duke University. They examined factors contributing to clinical inertia in the treatment of 296 veterans. They found that for the 1,216 intervention alerts triggered by an elevated 2-week mean home BP, physicians intensified treatment in 40.6 percent of cases. The most common (53.7 percent) reason given by physicians for not intensifying treatment was their perception that the reported blood pressure was actually acceptable despite the intervention alert. In these cases, the average home BP was 135/76 in contrast to the 143/81 average BP for alerts that resulted in physicians intensifying treatment.
"Blood pressure acceptable" intervention alerts were associated with the lowest level of repeat alerts, meaning that repeat blood pressure elevations occurred less frequently. When considering whether to intensify antihypertensive therapy when home BP is only mildly elevated, physicians must take into account factors such as patient preferences and values, medication burden, and other medical or personal circumstances along with absolute BP values. The researchers concluded that knowing when not to intervene by intensifying treatment, as well as when to intervene, is part of good clinical practice. This study was supported, in part, by the Agency for Healthcare Research and Quality (T32 HS000079).
See "Treatment intensification in a hypertension telemanagement trail: Clinical inertia or good clinical judgment?" by Matthew J. Crowley, M.D., Valerie A. Smith, M.S., Maren K. Olsen, Ph.D., and others in Hypertension 58, pp. 552-558, 2011.
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