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Raveendran AV. Clinical Inertia: A Wider Perspective and Proposed Classification Criteria. Indian J Endocrinol Metab 2023; 27:296-300. [PMID: 37867979 PMCID: PMC10586553 DOI: 10.4103/ijem.ijem_119_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/04/2023] [Accepted: 04/22/2023] [Indexed: 10/24/2023] Open
Abstract
Clinical inertia is very common in day-to-day practice, and the factors contributing to that can be physician-related, patient-related, or health-care-related. Clinical inertia is commonly described in chronic asymptomatic illness. We searched the PubMed and Scopus databases for original articles and reviews. Based on the search result, in this review article, we redefine various terminologies to avoid confusion and propose classification criteria for the early identification of clinical inertia. Clinical inertia is also present in acute illness and in symptomatic disease. Early identification of clinical inertia is difficult because of very vague terminologies which have been used interchangeably as well as because of the lack of definitive classification criteria. In this article, we redefine clinical inertia and propose criteria for early identification, which will be useful for both clinicians and academicians. This review will help clinicians to identify and rectify various aspects of clinical inertia.
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Safety and efficacy of a cardiovascular polypill in people at high and very high risk without a previous cardiovascular event: the international VULCANO randomised clinical trial. BMC Cardiovasc Disord 2022; 22:560. [PMID: 36550424 PMCID: PMC9773517 DOI: 10.1186/s12872-022-03013-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cardiovascular (CV) polypills are a useful baseline treatment to prevent CV diseases by combining different drug classes in a single pill to simultaneously target more than one risk factor. The aim of the present trial was to determine whether the treatment with the CNIC-polypill was at least non-inferior to usual care in terms of low-density lipoprotein cholesterol (LDL-c) and systolic BP (SBP) values in subjects at high or very high risk without a previous CV event. METHODS The VULCANO was an international, multicentre open-label trial involving 492 participants recruited from hospital clinics or primary care centres. Patients were randomised to the CNIC-polypill -containing aspirin, atorvastatin, and ramipril- or usual care. The primary outcome was the comparison of the mean change in LDL-c and SBP values after 16 weeks of treatment between treatment groups. RESULTS The upper confidence limit of the mean change in LDL-c between treatments was below the prespecified margin (10 mg/dL) and above zero, and non-inferiority and superiority of the CNIC-polypill (p = 0.0001) was reached. There were no significant differences in SBP between groups. However, the upper confidence limit crossed the prespecified non-inferiority margin of 3 mm Hg. Significant differences favoured the CNIC-polypill in reducing total cholesterol (p = 0.0004) and non-high-density lipoprotein cholesterol levels (p = 0.0017). There were no reports of major bleeding episodes. The frequency of non-serious gastrointestinal disorders was more frequent in the CNIC-polypill arm. CONCLUSION The switch from conventional treatment to the CNIC-polypill approach was safe and appears a reasonable strategy to control risk factors and prevent CVD. Trial registration This trial was registered in the EU Clinical Trials Register (EudraCT) the 20th February 2017 (register number 2016-004015-13; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2016-004015-13 ).
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Yan X, Stewart WF, Husby H, Delatorre-Reimer J, Mudiganti S, Refai F, Hudnut A, Knobel K, MacDonald K, Sifakis F, Jones JB. Persistent Cardiometabolic Health Gaps: Can Therapeutic Care Gaps Be Precisely Identified from Electronic Health Records. Healthcare (Basel) 2021; 10:70. [PMID: 35052233 PMCID: PMC8775887 DOI: 10.3390/healthcare10010070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
The objective of this study was to determine the strengths and limitations of using structured electronic health records (EHR) to identify and manage cardiometabolic (CM) health gaps. We used medication adherence measures derived from dispense data to attribute related therapeutic care gaps (i.e., no action to close health gaps) to patient- (i.e., failure to retrieve medication or low adherence) or clinician-related (i.e., failure to initiate/titrate medication) behavior. We illustrated how such data can be used to manage health and care gaps for blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and HbA1c for 240,582 Sutter Health primary care patients. Prevalence of health gaps was 44% for patients with hypertension, 33% with hyperlipidemia, and 57% with diabetes. Failure to retrieve medication was common; this patient-related care gap was highly associated with health gaps (odds ratios (OR): 1.23-1.76). Clinician-related therapeutic care gaps were common (16% for hypertension, and 40% and 27% for hyperlipidemia and diabetes, respectively), and strongly related to health gaps for hyperlipidemia (OR = 5.8; 95% CI: 5.6-6.0) and diabetes (OR = 5.7; 95% CI: 5.4-6.0). Additionally, a substantial minority of care gaps (9% to 21%) were uncertain, meaning we lacked evidence to attribute the gap to either patients or clinicians, hindering efforts to close the gaps.
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Affiliation(s)
- Xiaowei Yan
- Sutter Center for Health System Research, 2121 N. California Blvd, Suite 310, Walnut Creek, CA 94596, USA; (H.H.); (S.M.); (J.B.J.)
| | | | - Hannah Husby
- Sutter Center for Health System Research, 2121 N. California Blvd, Suite 310, Walnut Creek, CA 94596, USA; (H.H.); (S.M.); (J.B.J.)
| | - Jake Delatorre-Reimer
- Formerly Sutter Health Research, 2121 N. California Blvd, Suite 310, Walnut Creek, CA 94596, USA; (J.D.-R.); (F.R.)
| | - Satish Mudiganti
- Sutter Center for Health System Research, 2121 N. California Blvd, Suite 310, Walnut Creek, CA 94596, USA; (H.H.); (S.M.); (J.B.J.)
| | - Farah Refai
- Formerly Sutter Health Research, 2121 N. California Blvd, Suite 310, Walnut Creek, CA 94596, USA; (J.D.-R.); (F.R.)
| | | | - Kevin Knobel
- Sutter Gould Medical Foundation, Modesto, CA 95355, USA;
| | - Karen MacDonald
- Formerly AstraZeneca, Wilmington, DE 19897, USA; (K.M.); (F.S.)
| | | | - James B. Jones
- Sutter Center for Health System Research, 2121 N. California Blvd, Suite 310, Walnut Creek, CA 94596, USA; (H.H.); (S.M.); (J.B.J.)
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Ali DH, Kiliç B, Hart HE, Bots ML, Biermans MCJ, Spiering W, Rutten FH, Hollander M. Therapeutic inertia in the management of hypertension in primary care. J Hypertens 2021; 39:1238-1245. [PMID: 33560056 DOI: 10.1097/hjh.0000000000002783] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic inertia is considered to be an obstacle to effective blood pressure (BP) control. AIMS To identify patient characteristics associated with therapeutic inertia in patients with hypertension managed in primary care and to assess reasons not to intensify therapy. METHODS A Dutch cohort study was conducted using electronic health record data of patients registered in the Julius General Practitioners' Network (n = 530 564). Patients with a diagnosis of hypertension, SBP at least 140 and/or DBP at least 90 mmHg, and one or two BP-lowering drug(s) were included. Therapeutic inertia was defined as not undertaking therapeutic action in follow-up despite uncontrolled BP. Multivariable logistic regression was used to identify characteristics associated with inertia. Furthermore, an exploratory survey was performed in which general practitioners of 114 patients were asked for reasons not to intensify treatment. RESULTS We identified 6400 (10% of all patients with hypertension) uncontrolled patients on one or two BP-lowering drugs. Therapeutic inertia was 87%, similar in men and women. Older age, lower systolic, diastolic and near-target SBP, and diabetes were positively associated, while renal insufficiency and heart failure were inversely related to inertia. General practitioners did not intensify therapy because they first, considered office BP measurements as nonrepresentative (27%); second, waited for next BP readings (21%); third, wanted to optimize lifestyle first (19%). Eleven percent of patients explicitly did not want to change treatment. CONCLUSION Therapeutic inertia is common in primary care patients with uncontrolled hypertension. Older age, and closer to target BP, but also concurrent diabetes were associated with inertia.
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Affiliation(s)
- Dalia H Ali
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University
| | - Birsen Kiliç
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University
| | - Huberta E Hart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University
- Leidsche Rijn Julius Health Center
| | - Michiel L Bots
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht
| | - Marion C J Biermans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University
| | - Monika Hollander
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University
- Leidsche Rijn Julius Health Center
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Sabio R, Parodi R, Coca A. [Impact of cognitive biases in therapeutic inertia in arterial hypertension: Not everything is as it seems]. HIPERTENSION Y RIESGO VASCULAR 2020; 37:78-81. [PMID: 31542309 DOI: 10.1016/j.hipert.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/12/2019] [Accepted: 07/19/2019] [Indexed: 12/13/2022]
Abstract
Therapeutic inertia is defined as the failure to take therapeutic decisions, such as initiating, adding or increasing the dose of a drug during patient follow-up, despite there being an indication to do so. It is currently considered that therapeutic inertia is a considerable impediment to achieving adequate control of hypertension, and this has implications for the prognosis of the disease. Therapeutic inertia might be due to various factors involving physicians, patients and the health system. Many studies have attempted to find determinants for therapeutic inertia in hypertension and to explain the reasons why health professionals in charge of treatment are failing to make the appropriate modifications to therapy. The many reasons for therapeutic inertia on the part of physicians include the various cognitive and affective biases that influence clinical reasoning and decision-making during healthcare activity in doctors' surgeries. Identifying and recognising these cognitive and affective biases could be important for planning educational strategies for health professionals. This requires a multi-dimensional approach, including knowledge beyond that observed in terms of insufficient information and updating on the disease, and starting to analyse and consider other reasons. Preventing therapeutic inertia should be made a priority along with other important measures to control hypertension and minimise its consequences.
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Affiliation(s)
- R Sabio
- Servicio de Medicina Interna, Hospital SAMIC de Alta Complejidad, El Calafate, Argentina.
| | - R Parodi
- Servicio de Medicina Interna, Hospital Provincial Centenario, Rosario, Argentina
| | - A Coca
- Unidad de Hipertensión y Riesgo Vascular, Servicio de Medicina Interna, Hospital Clínico, Universidad de Barcelona, Barcelona, España
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Pallarés-Carratalá V, Bonig-Trigueros I, Palazón-Bru A, Esteban-Giner MJ, Gil-Guillén VF, Giner-Galvañ V. Clinical inertia in hypertension: a new holistic and practical concept within the cardiovascular continuum and clinical care process. Blood Press 2019; 28:217-228. [PMID: 31023106 DOI: 10.1080/08037051.2019.1608134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose: Recognition of clinical inertia is essential to improve the control of chronic diseases. Although it is very intuitive, a better interpretation of the concept of clinical inertia is lacking, likely due to its high complexity. Materials and Methods: After a review of the published articles, we propose a practical vision of inertia, contextualized within the clinical process of hypertension care. Results: This new vision enables the integration of previous terms and definitions of clinical inertia, as well as proposing specific strategies for its reduction. Conclusion: Although some concepts should be considered as 'justified inertia' or 'investigator inertia', the idea that inertia may be present throughout the continuum of care gives physicians a holistic view of the problem that is easily applicable to their clinical practice. Measures to overcome inertia are complicated because of the intrinsic complexity of the concept.
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Affiliation(s)
- Vicente Pallarés-Carratalá
- a Health Surveillance Unit , Castellón Mutual Insurance Union , Castellón de la Plana , Spain.,b Department of Medicine , Jaume I University , Castellón de la Plana , Spain
| | - Irene Bonig-Trigueros
- c Department of Internal Medicine (Cardiovascular Prevention Unit) , La Plana Hospital , Vila-Real , Spain
| | - Antonio Palazón-Bru
- d Department of Clinical Medicine , Miguel Hernández University , San Juan de Alicante , Spain
| | - María José Esteban-Giner
- e Department of Internal Medicine (Hypertension and Cardiometabolic Risk Unit) , Mare de Déu dels Lliris Hospital , Alcoy , Spain
| | - Vicente Francisco Gil-Guillén
- d Department of Clinical Medicine , Miguel Hernández University , San Juan de Alicante , Spain.,f Research Unit General University Hospital of Elda , Elda , Spain
| | - Vicente Giner-Galvañ
- e Department of Internal Medicine (Hypertension and Cardiometabolic Risk Unit) , Mare de Déu dels Lliris Hospital , Alcoy , Spain
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Castrillón-Spitia JD, Franco-Hurtado A, Garrido-Hernández C, Jaramillo-Patiño J, Londoño-Moncada MA, Machado-Alba JE. Utilización de fármacos antihipertensivos, efectividad e inercia clínica en pacientes. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Milman T, Joundi RA, Alotaibi NM, Saposnik G. Clinical inertia in the pharmacological management of hypertension: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11121. [PMID: 29924011 PMCID: PMC6025046 DOI: 10.1097/md.0000000000011121] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Clinical Inertia is defined as "failure of health care providers to initiate or intensify therapy according to current guidelines". This phenomenon is gaining increasing attention as a major cause of clinicians' failure to adequately manage hypertension, thus leading to an increased incidence of cardiovascular events. We performed a systematic review and meta-analysis of randomized controlled trials to determine whether interventions aimed at reducing clinical inertia in the pharmacological treatment of hypertension improve blood pressure (BP) control. METHODS MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched from the start of their database until October 3, 2017 for the MESH terms "Hypertension" or "Blood Pressure", their subheadings, and the keywords "Therapeutic Inertia" or "Clinical Inertia". Studies were included if they addressed pharmacologic hypertension management, clinical inertia, were randomized controlled trials, reported an outcome describing prescriber behavior, and were available in English. Data for the included studies was extracted by two independent observers. Quality of studies was analyzed using the Cochrane Risk of Bias Assessment. Data was pooled for statistical analysis using both fixed- and random-effects models. The primary study outcome was the percentage of patients achieving blood pressure control as defined by the Joint National Committee guidelines or study authors. RESULTS Of 474 citations identified, ten met inclusion criteria comprising a total of 26,871 patients, and eight were selected for meta-analysis. Interventions included Physician Education, Physician Reminders, Patient Education, Patient Reminders, Ambulatory BP Monitoring, Digital Medication Offerings, Physician Peer Visits, and Pharmacist-led Counselling. Pooled event rates revealed more patients with controlled BP in the intervention group versus control (55%, 95% CI 46-63% versus 45%, 95% CI 37-53%) and interventions significantly improved the odds of BP control (OR = 1.19, 95% CI = 1.12-1.27, P < .001). Heterogeneity in the quantitative analysis was moderate. CONCLUSIONS & RELEVANCE Addressing clinical inertia through physician reminders, ambulatory BP monitoring, and educational interventions for primary care providers was associated with an improvement in blood pressure control. Our findings encourage further research to investigate strategies at reducing clinical inertia in the management of hypertension.
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Affiliation(s)
- Tal Milman
- Faculty of Medicine Division of Neurology, Department of Medicine Division of Neurosurgery, Department of Surgery St. Michael's Hospital Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
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Carratala-Munuera C, Gil-Guillen VF, Orozco-Beltran D, Maiques-Galan A, Lago-Deibe F, Lobos-Bejarano JM, Brotons-Cuixart C, Martin-Rioboo E, Alvarez-Guisasola F, Lopez-Pineda A. Barriers to improved dyslipidemia control: Delphi survey of a multidisciplinary panel. Fam Pract 2015; 32:672-80. [PMID: 26089296 DOI: 10.1093/fampra/cmv038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To assess the barriers that make it difficult for the health care professionals (physicians, nurses and health care managers) to achieve a better control for dyslipidemia in Spain. METHODS The study has an observational design and was performed using the modified Delphi technique. One hundred and forty-nine panel members from medicine, nursing and health care management fields and from different Spanish regions were selected randomly and were invited to participate. Individual and anonymous opinions were asked by answering a 42-items questionnaire via e-mail (two rounds were done). Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the three groups (Kappa index and McNemar chi-square). RESULTS Response rate: 81%. The agreement index was 33.3 (95% CI: 18.9-47.7). Regarding the non-compliance with therapy, it improves with patient education degree in dyslipidemia, patient motivation, the agreement on decisions with the patient and with the use of cardiovascular risk measure and it gets worse with lack of information on the objectives to achieve. Clinical inertia improves with professional's motivation, cardiovascular risk calculation, training on objectives and the use of indicators and it gets worse with lack of treatment goals. CONCLUSION Different perceptions and attitudes between medicine, nursing and health care management were found. An agreement in interventions in non-compliance and clinical inertia to improve dyslipidemia control was reached.
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Affiliation(s)
| | | | | | - Antonio Maiques-Galan
- Family Medicine, Manises Primary Health Care Center, Valencia Health Agency, Valencia
| | - Fernando Lago-Deibe
- Family Medicine, Sardoma Primary Health Care Center, Galician Health Service, Vigo
| | | | - Carlos Brotons-Cuixart
- Research Unit, Sardenya Primary Health Care Center, Biomedical Research Institute Sant Pau, Barcelona
| | - Enrique Martin-Rioboo
- Family Medicine, Fuensanta Clinical Management Unit, Reina Sofia Hospital, IMIBIC and Cordoba University, Cordoba and
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Machado-Duque ME, Ramírez-Valencia DM, Medina-Morales DA, Machado-Alba JE. Effectiveness and clinical inertia in the management of hypertension in patients in Colombia. ACTA ACUST UNITED AC 2015; 9:878-84. [PMID: 26454799 DOI: 10.1016/j.jash.2015.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/20/2015] [Accepted: 08/21/2015] [Indexed: 11/18/2022]
Abstract
Determine the effectiveness of treatment and the frequency of clinical inertia in the management of hypertension in Colombian patients. A retrospective study with prospective follow-up of individuals on antihypertensive medication who were treated on medical consultation for 1 year was conducted in 20 Colombian cities. Clinical inertia was considered when no modification of therapy occurred despite not achieving control goals. A total of 355 hypertensive patients were included. From a total of 1142 consultations, therapy was effective in 81.7% of cases. In 18.3% of the cases, the control goal was not achieved, and of these, 81.8% were considered clinical inertia. A logistic regression showed that the use of antidiabetics (odds ratio: 2.31; 95% confidence interval: 1.290-4.167; P = .008) was statistically associated with an increased risk of clinical inertia. With a determination of the frequency of inertia and the high effectiveness of antihypertensive treatment, valuable information can be provided to understand the predictors of clinical inertia.
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Affiliation(s)
- Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | - Diana Marcela Ramírez-Valencia
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | - Diego Alejandro Medina-Morales
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia.
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Lebeau JP, Cadwallader JS, Aubin-Auger I, Mercier A, Pasquet T, Rusch E, Hendrickx K, Vermeire E. The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review. BMC FAMILY PRACTICE 2014; 15:130. [PMID: 24989986 PMCID: PMC4094689 DOI: 10.1186/1471-2296-15-130] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 06/24/2014] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jean-Pierre Lebeau
- Department of General Practice, EES, University of Tours, 10 Boulevard Tonnellé, BP 3223, 37032 Tours, Cedex 1, France
| | - Jean-Sébastien Cadwallader
- Department of General Practice, EES, University of Tours, 10 Boulevard Tonnellé, BP 3223, 37032 Tours, Cedex 1, France
| | - Isabelle Aubin-Auger
- Department of General Practice, University Paris Diderot, Sorbonne Paris Cité, France
| | - Alain Mercier
- Department of General Practice, University of Rouen, Rouen, France
| | - Thomas Pasquet
- Department of General Practice, EES, University of Tours, 10 Boulevard Tonnellé, BP 3223, 37032 Tours, Cedex 1, France
| | - Emmanuel Rusch
- Department of Public Health, EES, University of Tours, Tours, France
| | - Kristin Hendrickx
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Etienne Vermeire
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
- Department of Nursing and Midwifery, University of Antwerp, Antwerp, Belgium
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Evolution of therapy inertia in primary care setting in Spain during 2002–2010. J Hypertens 2014; 32:1138-45; discussion 1145. [DOI: 10.1097/hjh.0000000000000118] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Orozco-Beltran D, Ruescas-Escolano E, Navarro-Palazón AI, Cordero A, Gaubert-Tortosa M, Navarro-Perez J, Carratalá-Munuera C, Pertusa-Martínez S, Soler-Bahilo E, Brotons-Muntó F, Bort-Cubero J, Nuñez-Martinez MA, Bertomeu-Martinez V, Gil-Guillen VF. Effectiveness of a new health care organization model in primary care for chronic cardiovascular disease patients based on a multifactorial intervention: the PROPRESE randomized controlled trial. BMC Health Serv Res 2013; 13:293. [PMID: 23915267 PMCID: PMC3744171 DOI: 10.1186/1472-6963-13-293] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/18/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To evaluate the effectiveness of a new multifactorial intervention to improve health care for chronic ischemic heart disease patients in primary care. The strategy has two components: a) organizational for the patient/professional relationship and b) training for professionals. METHODS/DESIGN Experimental study. Randomized clinical trial. Follow-up period: one year. STUDY SETTING primary care, multicenter (15 health centers). For the intervention group 15 health centers are selected from those participating in ESCARVAL study. Once the center agreed to participate patients are randomly selected from the total amount of patients with ischemic heart disease registered in the electronic health records. For the control group a random sample of patients with ischemic heart disease is selected from all 72 health centers electronic records. DISCUSSION This study aims to evaluate the efficacy of a multifactorial intervention strategy involving patients with ischemic heart disease for the improvement of the degree of control of the cardiovascular risk factors and of the quality of life, number of visits, and number of hospitalizations. TRIAL REGISTRATION NCT01826929.
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Affiliation(s)
- Domingo Orozco-Beltran
- Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | - Esther Ruescas-Escolano
- Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | - Ana Isabel Navarro-Palazón
- Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | - Alberto Cordero
- Servicio de Cardiología, Hospital Universitario de Sant Joan d’ Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | - María Gaubert-Tortosa
- Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | | | - Concepción Carratalá-Munuera
- Cátedra de Medicina de Familia. Departamento Medicina Clínica, Universidad Miguel Hernández, Ctra. Nnal. 332 Alicante-Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | | | | | | | - Jose Bort-Cubero
- CS Carinyena c/Illes Columbretes, s/n 12540, Vila-Real, Castellon, Spain
| | - Miguel Angel Nuñez-Martinez
- Unidad de docencia e investigación, Hospital Universitario de Sant Joan d’Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | - Vicente Bertomeu-Martinez
- Servicio de Cardiología, Hospital Universitario de Sant Joan d’ Alacant, Ctra. Nnal. 332 Alicante, Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
| | - Vicente Francisco Gil-Guillen
- Cátedra de Medicina de Familia. Departamento Medicina Clínica, Universidad Miguel Hernández, Ctra. Nnal. 332 Alicante-Valencia s/n, Sant Joan d’Alacant Alicante 03550, Spain
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14
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Gil-Guillén V, Orozco-Beltrán D, Carratalá-Munuera C, Márquez-Contreras E, Durazo-Arvizu R, Cooper R, Pertusa-Martínez S, Pita-Fernandez S, González-Segura D, Martin-de-Pablo JL, Pallarés V, Fernández A, Redón J. Clinical inertia in poorly controlled elderly hypertensive patients: a cross-sectional study in Spanish physicians to ascertain reasons for not intensifying treatment. Am J Cardiovasc Drugs 2013; 13:213-9. [PMID: 23585143 DOI: 10.1007/s40256-013-0025-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical inertia, the failure of physicians to initiate or intensify therapy when indicated, is a major problem in the management of hypertension and may be more prevalent in elderly patients. Overcoming clinical inertia requires understanding its causes and evaluating certain factors, particularly those related to physicians. OBJECTIVE The objective of our study was to determine the rate of clinical inertia and the physician-reported reasons for it. METHODS An observational, cross-sectional, multi-center study was carried out in a primary care setting. We included 512 physicians, with a consecutive sampling of 1,499 hypertensive patients with clinical inertia. MAIN OUTCOME MEASURE Clinical inertia was defined when physicians did not modify treatment despite knowing that the therapeutic target had not been reached. Clinical inertia was considered to be justified (JCI) when physicians provided an explanation for not intensifying treatment and as not justified (nJCI) when no reasons were given. RESULTS JCI was observed in 30.1 % (95 % CI 27.8-32.4) of patients (n = 451) and nJCI in 69.9 % (95 % CI 67.6-72.2) (n = 1,058). JCI was associated with higher blood pressure (BP) values (both systolic and diastolic) and diabetes (p = 0.012) than nJCI. nJCI was associated with patients having an isolated increase of systolic or diastolic or high borderline BP values or cardiovascular disease. CONCLUSION Physicians provided reasons for not intensifying treatment in poorly controlled patients in only 30 % of instances. Main reasons for not intensifying treatment were borderline BP values, co-morbidity, suspected white coat effect, or perceived difficulty achieving target. nJCI was associated with high borderline BP values and cardiovascular disease.
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Affiliation(s)
- Vicente Gil-Guillén
- Cátedra de Medicina de Familia, Departamento de Medicina Clínica, Universidad Miguel Hernández, Ctra. De Valencia N332 Km 87, San Juan, 03550, Alicante, Spain.
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15
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Klein R, Branch WT. Clinical Inertia Remains a Problem. Drugs Aging 2011; 28:943-4. [DOI: 10.2165/11598370-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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