Therapeutic Inertia of Hypertension and Physician Logic

Background: Therapeutic Inertia (TI), the lack of escalation or initiation of blood pressure (BP) lowering medications during clinic visits with BP ≥ 140/90 mmHg occurs in majority of clinic visits among older adults. It remains a major barrier for achieving BP control. We reviewed a random selection of university affiliated outpatient primary care clinics with documented TI to elucidate reasons for not escalating treatment. Methods: The source population included 7215 patients aged ≥65 with ICD-10 diagnosis of hypertension and ≥1 visit with uncontrolled BP at a university-affiliated clinic from January 2019 to December 2020. Uncontrolled BP was defined as a clinic systolic BP ≥140 mmHg and/or diastolic BP ≥ 90 mmHg confirmed with blood pressure measured 3 times in 1-minute intervals and averaged. Two investigators reviewed 101 unique patient outpatient clinic visits with documented TI in source population. A priori, reasons for TI were categorized as acute symptoms/illness, stress/pain, noncompliance, patient refusal, side effects and documentation of home BP < 140/90 mmHg. If more than one reason was present in a note, all reasons were included. Results: The mean age of the 101 patients was 76.2 years (Standard Deviation [SD] 8.7) during the clinic visist. Comorbidities included diabetes mellitus in 35%, chronic kidney disease in 13% and cardiovascular diseases in 35%; 90% were covered by Medicare insurance. The mean total number of BP lowering medications was 1.8 (SD 0.92). Overall, 38% of charts lacked documentation justifying the TI; 51% overall had uncontrolled blood pressure at the subsequent clinic visit. Figure 1 shows the documented reasons for TI. Acute medical illness was the most common justification found(17%). No encounter had documentation of orthostatic hypotension. Overall 38% of encounters lacked documentation justifying the TI. Conclusion: TI is common among older adults and may be due to clinician attention to acute illnesses, pain and stress. However, a substantial proportion of TI may not be justified.Figure 1