Therapeutic inertia in the management of hypertension in primary care

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.