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There is a perception that physicians are doing a poor job of treating hypertension despite the availability of effective, well-tolerated therapy. We are reminded that only about 35% to 40% of patients with elevated blood pressure (BP) have their BP controlled to goal levels and that only about 60% are receiving antihypertensive medication.1 Some of these data may be 4 or more years out of date. Recent surveys in large group practices or national polls note that as many as 90% of patients appear to be receiving treatment with some medication and that >50% of the respondents state that their BP is controlled to levels below the presently accepted goal of 140/90 mm Hg.2,3 Admittedly, some of these data are “soft,” but it is clear that we are doing a better job than some would have us believe; obviously, there is more that we can do. Physician or clinical inertia has been one reason cited to explain less than ideal treatment results.

Physician Inertia

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References

Physician inertia is defined as the failure to initiate therapy or to intensify or change therapy in patients with BP values >140/90 mm Hg, or >130/80 mm Hg in hypertensive patients with diabetes, renal, or coronary heart disease. The term clinical or physician inertia has been used to describe situations in which patients return for visits having taken their medication but have not had therapy changed despite BP levels that are higher than levels established by guidelines.4 It has also been applied with regard to the large number of patients (usually older than 60 years) with systolic hypertension for whom physicians are reluctant to provide any specific treatment. About one-third of patients whose BP values are consistently above goal levels do not have medication started, changed, or increased.2,5,6 In patients with comorbid conditions, about 50% do not have treatment changed despite persistently elevated BP, and despite guidelines that physicians claim to accept, many physicians do not attempt to treat elevated systolic BP until it is >150 mm Hg.7,8 These patients, as noted, compose a majority of the people included in the “not at goal” group.

Patient adherence to therapy is another major problem, but first it may be of interest to review the results of therapy even when BP was not reduced to the goal levels that have been used to define adherence.

Results of Treatment Without Achieving “Goal” BP in Many Patients

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References

It is self-evident that lowering BP is effective in reducing morbidity/mortality not just from cerebrovascular but also from cardiovascular events.9,10 Treatment of hypertension in the United States has resulted in dramatic decreases in morbidity/mortality—a decrease greater than noted in other industrialized countries. It is important to remind ourselves that strokes and stroke deaths have been reduced by >60% since the 1970s when the National High Blood Pressure Education Program began. A large part of this decrease is attributable to better treatment of hypertension. Rates of congestive heart failure from hypertension have decreased by >50%; progression from less severe to more severe hypertension as well as coronary events and progression of renal disease have also decreased dramatically.9,10 There is nothing new about these data.

Lowering BP to the presently recommended guidelines of <140/90 mm Hg in those with uncomplicated hypertension or to <130/80 mm Hg in patients with diabetes, renal disease, or coronary heart disease has become the objective of clinical trials and national efforts.11 These are arbitrary levels but have been established as cut points to define treatment goals. Clinical trials in which specific protocols are followed, with free medication, a great deal of ancillary help, and systematic follow-ups, have reported that diastolic BP values can be reduced to <90 mm Hg in >90% of patients but that only about 60% have their systolic BP values reduced to <140 mm Hg.12 These results have been widely publicized and used as examples of what can be accomplished with a goal-oriented approach. At present, these goals are not being achieved in many clinical settings. But in many trials in which benefits have been reported, BP values have not been lowered to <140/90 mm Hg in a large number of patients.13–15

Which Patients Are Not Experiencing BP Control?

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References

The large majority of patients who do not experience the recommended reduction in BP to goal levels are elderly (ie, older than 60). Most have isolated systolic hypertension, defined most recently as BP values >140/<90 mm Hg. It is clear that most instances of reported poor control rates relate to poor control of systolic BP.

Causes of Poor Physician and Patient Adherence to Therapy

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References

Are physician or clinical inertia and/or poor patient adherence to therapy the major causes of the problem in most cases of poor BP control? Are there some patients whose BP cannot be reduced and controlled to goal levels despite adequate care and adherence to a treatment regimen?16 For years, patient adherence or compliance was advanced as a major cause for the lack of better treatment results: patients’ failure to return for visits, patients’ failure to fill prescriptions because of cost concerns, patients’ lack of awareness of the significance of elevated BP or its complications, or patients just forgetting. When asked why a higher percentage of patients do not have BP controlled, many physicians repeat these patient-related factors. In recent years, however, numerous investigators have suggested that barriers to the effective management of uncontrolled hypertension also include many physician-related problems: lack of concern for higher than ideal but “not very high” pressures; complexity of prescribing or monitoring drug regimens; physician practice patterns; lack of physician-patient rapport or trust; failure to communicate the importance of continuing therapy; lack of ongoing attention to asymptomatic diseases such as hypertension in patients with symptomatic comorbidities such as arthritis, diabetes, or pulmonary disease; and concern about drug adverse effects. Some of these issues can actually be addressed within the context of the time constraints of managed care.

Patient Education

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References

One of the ways to reduce physician inertia is to improve the patients’ understanding of why it is important to treat hypertension effectively.17 We have long been critical of the fact that much lip service but not much effort is given to patient education.18 In the present world of managed care and limitations of physicians’ time with patients, it is more important than ever that educational materials be made available to patients. For many years, the National High Blood Pressure Education Program distributed booklets on hypertension for patients; there are also many educational materials on hypertension available from the American Heart Association and other organizations such as the Hypertension Education Foundation (hypertensionfoundation.org). These are not being used. Look around your own office or check the offices of other internists, family physicians, or cardiologists. It is rare to find any material about hypertension in the waiting or treatment rooms. Contrast this to the offices of nose and throat physicians, orthopedists, or dentists, where relevant materials are readily available. One of the first things that must be done to improve patient adherence and indirectly to reduce clinical inertia is to provide more up-to-date educational material and to make the patient proactive in understanding the reasons for therapy and insisting on changes in therapy if BP is not at goal levels. This will not solve the problem of inertia, but it will help.

In addition, physicians must be more active in conveying the message that treatment of hypertension is necessary and highly effective in reducing disease. Yes, there are time constraints, but the message should be that (1) elevated BP may exist without symptoms and should be treated; (2) treatment is generally lifelong; (3) lifestyle changes that are advocated might work in some cases of less severe hypertension, but in most cases medication is necessary; (4) 1 medication may not be effective (2 or 3 may be necessary); (5) if BP values are reduced to normal, medication should not be stopped; and finally (6) if medication is taken as prescribed and BP values are reduced, many of the complications, like stroke and heart failure, will be prevented.

Many years ago, we tested the time it took to deliver this type of message. It can be accomplished in less than 2 to 3 minutes. It should be part of the physician’s responsibility to keep the patient informed. In turn, an informed patient will serve as a reminder to the provider to treat hypertension more effectively.

At What BP Level Should Treatment Be Started, Especially in the Elderly?

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References

As noted, studies have suggested that many physicians do not begin specific treatment unless the systolic BP is >150 mm Hg despite good epidemiologic evidence that morbidity/mortality are increased at these levels when compared to systolic BP values <140 mm Hg.14 They are reluctant to treat older patients who feel well, especially when they are older than 75 to 80, despite data that lowering systolic BP in this population will reduce strokes, heart failure, and coronary heart disease events.15 Concern for adverse effects, especially hypotension or weakness, is also a factor in the elderly population. In our experience, however, and in the clinical trials, these were not major concerns—if BP is lowered gradually and monitored in the upright position. The higher BP levels that some physicians use as criteria for beginning therapy may explain a great deal of physician inertia.

One might argue that in the trials, such as the Systolic Hypertension in the Elderly (SHEP),13 the European Systolic Elderly (Syst-Eur) Trial,14 or the Hypertension in the Very Eldery Trial (HYVET),15 systolic BP was not reduced (on average) to <140 mm Hg and that a reduction of only 12 to 15 mm Hg reduced events: any lowering of BP is beneficial.

Why are guidelines insisting on a value <140 mm Hg as a goal without definitive data in this population? In the opinion of many experts, these guidelines—even if not yet proven in clinical trials—are reasonable based on good epidemiologic data and experience.

Some inertia is also the result of confusion as to which BP measure to use. Data suggest that some physicians are confused: should clinic or home BP readings be used for treatment decisions?14 Should ambulatory BP monitoring be performed to get the “true” BP? While data do suggest that home and ambulatory BP values may be somewhat better predictors of risk, we should remember that in all the trials, including studies in the elderly, clinic BP readings were used to determine outcome: the higher the “on-treatment” BP, the worse the outcome. BP was assessed just 4 to 6 times a year, and the values obtained were good predictors. While home BP values are useful for patient adherence and do provide some guidance regarding between-visit BP levels, clinic BP readings should, I believe, continue to be used to determine the initiation of therapy and changes in treatment, unless there is a disconnect between BP values and patients’ symptoms, for example, headaches or dizziness at home with normal office BP values. Home BP readings will help to determine whether BP values are higher or lower than in the office and to adjust treatment accordingly. This approach should help to remove the “confusion” aspect of the inertia question. While some experts may contend that we may be treating some white-coat hypertension unnecessarily, persistently elevated office or clinic systolic BP values in the elderly most commonly suggest pathology and should be lowered.

Finally, the presence of comorbidities appear to influence physician behavior. If a patient is being treated for painful arthritis, emphysema, asthma, or diabetes, their relatively asymptomatic hypertension may be ignored; a simple remedy for this problem is assessing BP routinely at office visits. If values are normal (<130/80 mm Hg) on several occasions over a 3- to 6-month period, then a 1-year interval is probably adequate. If BP values are >140/90 mm Hg, they should be treated.

Physician or clinical inertia can be reduced if the above recommendations are followed. It clearly is a problem but one that can be overcome to a great degree.

References

  1. Top of page
  2. Physician Inertia
  3. Results of Treatment Without Achieving “Goal” BP in Many Patients
  4. Which Patients Are Not Experiencing BP Control?
  5. Causes of Poor Physician and Patient Adherence to Therapy
  6. Patient Education
  7. At What BP Level Should Treatment Be Started, Especially in the Elderly?
  8. References