UAB Synopsis, Vol. 27, No. 4, February 4, 2008
Reasons for so-called clinical inertia are poorly understood, according to a December 2007 paper by UAB researchers published in the Journal of General Internal Medicine (22[12]:1648-1655). Lead author is Monika M. Safford, MD, associate professor, Division of Preventive Medicine.
Clinical inertia is defined as inaction by physicians caring for patients with uncontrolled risk factors, such as high blood pressure, and may account for up to 80% of cardiovascular events.
Dr. Safford’s group, funded by a Veterans Administration study she leads and an NIH-funded study led by senior author Jeroan J. Allison, MD, MSc, associate professor, Division of General Internal Medicine, derived an empiric conceptual model of clinical inertia as a subset of all clinical inactions. The nominal group technique was used to ask practicing primary physicians why they do not intensify medications.
When asked “When would you NOT intensify medications when the blood pressure is high?” primary care physicians responded with answers such as:
- Patient is not taking medications correctly;
- Patient demonstrates reactive hypertension;
- Patient’s intercurrent illness supersedes hypertension;
- Patient’s hypertension has been difficult to control and several medication adjustments have been tried previously;
- Patient is intolerant of medication side effects; and
- Patient cannot afford medications.
“Our findings suggest that many apparent ‘failures’ of physicians to intensify medication regimens reflect potentially appropriate decisions,” Dr. Safford writes in the journal. “Distinguishing potential clinical inertia from appropriate inaction is an important initial step for interventionists seeking to identify strategies to improve care and for policy makers seeking to measure health care quality.
“Our empirically derived model of clinical inaction suggests that from the physician perspective, appropriate inaction is an important component of the previous broad conceptualization of clinical inertia. Our model presents an alternative framework that can be used to differentiate appropriate inaction from potential true clinical inertia,” the article states. “Before performance measures for public accountability can be implemented, further studies to better define true clinical inertia, quantify its prevalence, and demonstrate variability suggestive of quality problems should be completed.”
Other UAB coauthors of the study are Professor Richard M. Shewchuk, PhD, and Graduate Assistant Haiyan Qu, PhD, Department of Health Services Administration; Graduate Assistant Jessica H. Williams, MPH, and Associate Professor Carlos A. Estrada, MD, MS, Division of General Internal Medicine; and Associate Professor Fernando Ovalle, MD, Division of Endocrinology, Diabetes, and Metabolism.