The failure of physicians to start or intensify treatment per the guidelines has gained traction in recent years. The phenomenon is termed “clinical inertia” and contributes to the mismanagement of serious chronic conditions, such as hypertension and diabetes.

Milman T, Joundi RA, Alotaibi NM, Saposnik G. Clinical inertia in the pharmacological management of hypertension: A systematic review and meta-analysis. Medicine. 2018;97(25):e11121.

 

The phenomenon of clinical inertia was first defined nearly 20 years ago. Ever since then, various population studies have demonstrated that adequate recommendations and guidelines have not been implemented in clinical practice.

Andreozzi F, Candido R, Corrao S, et al. Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review. Diabetol Metab Syndr. 2020;12(1):52.

 

 

Understanding the problem

 

Also known as therapeutic inertia, many reasons exist for clinical inertia in risk factor management. These include physician factors, patient factors, and aspects of the patient-physician relationships. 

Examples of patient characteristics are advanced age, decreased life expectancy, comorbidities, or patients who are either nearly at target or at some physician-defined “acceptable” target. 

Physician risk tolerance, decision making obfuscated by uncertainty, and ambiguity are also contributing factors. 

In an editorial published in Medicine Matters, authors highlight physician blind spots that may contribute to clinical inertia. “As physicians, we are adept at identifying clinical inertia in our peers,” they wrote. “However, we consistently overrate the quality of care that we ourselves provide, substantially underestimating the number of our own patients that are not meeting targets. When challenged with evidence of clinical inertia, we can be prone to making “soft excuses” for the avoidance of intensification: a lack of time to adequately discuss the new strategy; blaming the patient for non-adherence; or adopting a paternalistic approach.”

They also pointed out that, in all fairness, guidelines sometimes fail to keep abreast of the newest advances and proffer clear indications of which drug is indicated for which patient. Guidelines can also mandate individualized treatment goals without actionable instructions on reaching these goals. 

 

Clinical inertia in action

 

Various guidelines elucidate targets for the pharmacologic treatment of blood pressure, sugars, and lipids. Large randomized-controlled trials and systematic reviews have demonstrated that adherence to targets decreases the risk of heart disease and other negative health outcomes.

Research cited by the authors of a systematic review and meta-analysis published in Medicine cited research that treatment intensification for blood pressure occurred during only 16% of visits, with medication intensification initiation occurring during 26.4% of visits. 

Authors of a review published in Diabetology & Metabolic Syndrome shed light on the epidemiology of clinical inertia in diabetes management, which emerged as a topic of interest more than 10 years ago. For instance, in a Canadian cohort of 2,502 patients with type-2 diabetes and heightened HbA1c, fewer than half had their treatments intensified in 2005. Another study published in 2011 found that the median time to intensification was 14 months in US practices. Moreover, another high-power study found that HbA1c levels had to hit 8.9% before physicians prescribed insulin.

“Therapeutic inertia, particularly in the management of chronic diseases such as diabetes, is a very complex phenomenon that recognizes multiple causes, largely dependent on the health professionals, but also on the patient and on national healthcare, with significant impact on health outcomes, welfare and social cost,” wrote the authors.

“In the past, the balance between hypoglycemia and strict metabolic control was difficult to assess with a limited therapeutic arsenal, and inertia was somewhat explained by fear of hypoglycemia. Nowadays, we have drugs with a very-low risk of hypoglycemia, able to minimize cardiovascular and renal burden,” they added. 

Therefore, we have entered an era where inertia is ethically unacceptable.

 

Strategies to overcome clinical inertia

 

Various strategies have been presented to overcome clinical inertia. Although these approaches may vary by disease state, some overarching leitmotifs are apparent. These include the following:

• Physicians can adopt a monitoring system to analyze overall quality of care. 

• Risk-stratification software and algorithms can help identify appropriate avenues of care with regard to evidence-based guidelines.

• Physicians can use software that provides automated intensification strategies.

• Training courses at all levels of primary and specialty care can help further educate physicians on  treatment of chronic conditions, targets, guidelines, and new drugs.

• Physicians can implement one-on-one or small-group training to further elucidate treatment and intensification strategies (ie, academic detailing).

• Physicians can educate patients and improve their self-management skills to help with adherence.

• Multidisciplinary teams can pool input from various specialists and implement shared diagnostic plans.

“The challenge for clinicians is to try and negotiate shared goals which meet both disease outcomes and the patient’s priorities,” wrote the authors of the editorial published on Medicine Matters. “An individual is much more likely to adhere to treatments and interventions that are aligned with their own priorities in the context of their wider lives. Recognizing the effects that chronic health problems have on peoples’ lives goes some way to allowing these goals to develop.”