The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review

Background Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition. Methods A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method. Results The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), “who” (physician, patient or system), “how and why” (mechanisms and reasons), and “appropriateness”. Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation. Conclusions Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.

Bosworth Improving blood pressure control by tailored feedback to patients and clinicians.
USA Narrative review "Research has attributed these findings to a tendency for clinicians to use a higher threshold of clinic-based blood pressure to initiate regimen changes ("clinical inertia")

Spain
Randomized clinical trial "Therapeutic inertia (TI) is defined as the failure of the doctor or nurse in the initiation or maintenance treatment of a disease or risk factor when they are actually given, and despite knowing that following the protocols and practice guidelines is necessary do so. TI is a conservative attitude of professionals to the therapeutic decisions in managing different clinical situations that arise daily patients. It is a difficult concept to explain and justify. The reasons adduced are diverse, and among them include a lack of training, lack of confidence in the consensus, the lack of time in consultations and the complicated structure and health organization." J Clin Hypertens 2009,11:1-4.

Moser
Physician Belgium Narrative review [Translated from french] "Therapeutic inertia is the lack of initiation or intensification of therapy when blood pressure goals are unmet." "As for therapeutic inertia, the responsability lies in the practitioner's behaviour, continuing on his initial decisions." "There is a strong link between therapeutic inertia and awareness of cardiovascular risk, poor blood pressure control, and goals depending on the patient's cardiovascular risk and adherence to treatment." Rev Med Liege 2010,65:256-260.

Suarez
Clinical inertia in geriatrics. Belgium Narrative review [Translated from french] "Numerous causes lead to therapeutic inertia, i.e. 'lack of initiation or intensification of therapy when indicated' or 'recognition of the problem but failure to act'." "Not following the guidelines should not be considered therapeutic inertia when a treatment is interrupted due to side effects or intolerance." Rev Med Liege 2010,65:232-238.

Scheen
[Inertia in clinical practice: causes, consequences, solutions.] Belgium Expert opinion [Translated from french]"Therapeutic inertia is one of the components of clinical inertia. It mainly concerns the management of chronic diseases. It may be defined as the attitude of health care providers who do not initiate or intensify therapy appropriately despite recognition of the problem." "It does not concern pharmacological trzatment only, but also lifestyle counseling, too ofetne neglected, especially in preventive medicine." J Clin Hypertens 2010,12:502-507.

Sutton
Why physicians do not prescribe a thiazide diuretic.
USA Retrospective cohort study "Many of these reasons seem to indicate typical patterns of ''clinical inertia'' or failure to act when the BP is not controlled which contributes to overall poor BP control." "Many physicians do not intensify therapy when BP is close to goal." J Hypertens 2010;28:e282-283.

Van Der Niepen
Therapeutic inertia and the hawthorne effect in the management of hypertension: Results of the i-decide survey.

Belgium
Survey (poster) "...physician does not intend to modify the treatment, i.e. therapeutic inertia." "The most prevalent reasons for the no-change strategy choicewere 'the treatment is well tolerated' and'the clinical situation is acceptable'." J Am Soc Hypertens 2010,4: 244-254.

Viera
Level of blood pressure above goal and clinical inertia in a Medicaid population.

USA
Cohort study "The failure of clinicians to initiate or intensify antihypertensive therapy despite elevated BP levels has been termed clinical inertia One hypertension clinical action model conceptualizes clinical inertia as stemming from four domains organizational factors (e.g., sufficient support staff, access to follow-up), competing demands and prioritization (e.g., patients with several comorbidities or multiple complaints), medication related factors (e.g., number of medications, side effects), and Clinical uncertainty."