Context
- Why do clinicians fail to intensify antihypertensive therapy when a patient's blood pressure is elevated?
Contribution
- This study involved 1169 diabetic patients seen by 92 primary care providers at 9 Veterans Affairs facilities. All had elevated triage blood pressures, but only half received antihypertensive treatment intensification by providers. Patient reports of home blood pressures or repeated blood pressures by providers within normal limits and discussion of medication issues decreased the likelihood of antihypertensive intensification at clinic visits.
Implication
- Uncertainty about true blood pressure values may underlie many reasons why physicians do not intensify antihypertensive therapy.
—The Editors
Despite
some recent improvements in blood pressure control, the number of
patients with inadequate control remains high and contributes to excess
morbidity and mortality, especially among patients at high risk from
complications of hypertension (1 - 8).
Several studies have suggested that “clinical inertia”—the failure by
providers to initiate or intensify therapy (medication intensification)
in the face of apparent need to do so—is a main contributor to poor
control of hypertension (9 - 12).
Although
the failure to intensify treatment medications for patients with
elevated blood pressures at visits has been well documented ((5 - 6), (12 - 18)),
factors underlying what seems to be clinical inertia have been studied
less systematically. When providers are queried after clinic visits
about the lack of medication intensification for elevated blood
pressure, they variously report that the patient's “true” blood pressure
was lower than the clinic blood pressure reading, that other patient
concerns precluded attention on blood pressure management, and that
patient adherence should be improved before medication intensification
((6), (17)). Some studies have examined the role of various clinical and patient factors in intensification decisions ((6), (8), (17), (19 - 20)),
but no study has used a detailed conceptual model to comprehensively
examine the relative contribution of a broad array of potential patient,
provider, organizational, and visit-specific contributors to a
medication intensification decision. In addition, although a frequently
cited reason for deferring medication changes is that the clinic blood
pressure does not reflect the patient's “true” blood pressure (21 - 22), this clinical uncertainty and its effects have not been explored.
To
better understand factors underlying apparent clinical inertia for
hypertension, we designed the ABATe (Addressing Barriers to Treatment
for Hypertension) study to examine treatment change decisions for
diabetic primary care patients with elevated triage blood pressures
before a primary care visit. We defined elevated blood pressure for this
population to be 140/90 mm Hg, a value well above guideline targets for
diabetic patients and one clearly requiring some type of action (4).
Our goals were to assess how often patients presenting with an elevated
triage blood pressure received medication intensification or were
scheduled for close follow-up and the role that clinical uncertainty
about blood pressure, competing demands and prioritization,
medication-related factors, and care organization play in treatment
change decisions.
