System-level initiatives to reduce persistently elevated blood pressures in hypertensive patients: how do we overcome clinical inertia?

In the United States, research consistently shows around half of adults with hypertension do not achieve recommended control of their blood pressure (BP).1 Poor BP control at the population level then leads to higher rates of preventable negative cardiovascular outcomes, like strokes and heart attacks.

As recently reported, Elizabeth Pfoh and colleagues studied a quality improvement project for >110,000 hypertensive patients across the Cleveland Clinic Health System that aimed to increase the rate of BP control system-wide. The authors sought to determine which of two strategies might better improve documented improvement in BP control: remeasuring BP at follow-up visits or intensification of medication regimens.

This is important because of the problem known as clinical inertia,2 which describes delaying treatment initiation or intensification when patients do not achieve clinical targets such as BP control. It’s certainly true that clinicians may, in certain individual patients, be exercising good clinical judgment by not intensifying therapy.3 But clinical inertia is another matter – it involves not acting even when patients and populations might benefit. Known to increase the risk adverse clinical events, clinical inertia has many causes, including uncertainty about ‘true’ ambulatory BP measurements, competing demands for clinician attention during busy appointments, lack of timely follow-up, and patient nonadherence.4 Clinicians may avoid intensifying medication because they may worry they’ve caught the patient on a bad day, and decide to wait and remeasure on another day, or they may try lifestyle interventions first. Unfortunately, lifestyle changes are rarely enough to produce BP control.

In this study, the Cleveland Clinic system designed an intervention to emphasize the need to treat hypertension. It included staff and caregiver education on how to measure BP and the importance of controlling hypertension, implementation of a new follow-up ‘BP Recheck’ visit option staffed by nurses or pharmacists, and direct patient outreach for those who did not get scheduled for a ‘BP Recheck’ but were hypertensive in the office. Using the year prior to the intervention as a comparison, physicians intensified meds in both more individual hypertensive patients and in more clinic visits with hypertensive blood pressures in the year after the intervention. Additionally, doctors during the year post-intervention were more likely to intensify meds both in patients where the systolic BP was greater than and below 160 mmHg. Ultimately, the end result of these med changes was that a higher percentage of patients of patients had controlled BP readings at the end of the intervention year.

This study indicates that improving BP control at the system or population level may require concerted efforts to systematically add new meds or increase doses. Implementing multidisciplinary teams with data streams combining direct patient outreach with an emphasis on medication intensification has the potential to overcome clinical inertia. If replicable in other larger health systems, it may help to reduce preventable cardiovascular events.

 

E Pfoh et al. Impact of a system-wide quality improvement initiative on blood pressure control: a cohort analysis.

If you have ideas for improving medication intensification or thoughts on clinical inertia, please share in the comments below!

1Wall HK, Ritchey MD, Gillespie C, et al. Vital Signs: prevalence of key cardiovascular disease risk factors for Million Hearts 2022 – United States, 2011-16. MMWR Morb Mortal Wkly Rep. 2018;67:983-91.

2Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135:825-834.

3Crowley MJ, Smith VA, Olsen MK, et al. Treatment intensification in the hypertension telemanagement trial. Hypertension. 2011;58(4):552-8.

4Lebeau JP, Cadwallader JS, Aubin-Auger I, et al. The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review. BMC Fam Pract. 2014;15:130.

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