Skip to main content
Erschienen in: Journal of General Internal Medicine 12/2007

01.12.2007 | Original Article

Reasons for Not Intensifying Medications: Differentiating “Clinical Inertia” from Appropriate Care

verfasst von: Monika M. Safford, MD, Richard Shewchuk, PhD, Haiyan Qu, PhD, Jessica H. Williams, MPH, Carlos A. Estrada, MD, MS, Fernando Ovalle, MD, Jeroan J. Allison, MD, MSc

Erschienen in: Journal of General Internal Medicine | Ausgabe 12/2007

Einloggen, um Zugang zu erhalten

Abstract

Background

“Clinical inertia” has been defined as inaction by physicians caring for patients with uncontrolled risk factors such as blood pressure. Some have proposed that it accounts for up to 80% of cardiovascular events, potentially an important quality problem. However, reasons for so-called clinical inertia are poorly understood.

Objective

To derive an empiric conceptual model of clinical inertia as a subset of all clinical inactions from the physician perspective.

Methods

We used Nominal Group panels of practicing physicians to identify reasons why they do not intensify medications when seeing an established patient with uncontrolled blood pressure.

Measurements and Main Results

We stopped at 2 groups (N = 6 and 7, respectively) because of the high degree of agreement on reasons for not intensifying, indicating saturation. A third group of clinicians (N = 9) independently sorted the reasons generated by the Nominal Groups. Using multidimensional scaling and hierarchical cluster analysis, we translated the sorting results into a cognitive map that represents an empirically derived model of clinical inaction from the physician’s perspective. The model shows that much inaction may in fact be clinically appropriate care.

Conclusions/Recommendations

Many reasons offered by physicians for not intensifying medications suggest that low rates of intensification do not necessarily reflect poor quality of care. The empirically derived model of clinical inaction can be used as a guide to construct performance measures for monitoring clinical inertia that better focus on true quality problems.
Literatur
1.
Zurück zum Zitat Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339(27):1957–63.PubMedCrossRef Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339(27):1957–63.PubMedCrossRef
2.
Zurück zum Zitat Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Hypertension control: how well are we doing? Arch Intern Med. 2003;163(22):2705–11.PubMedCrossRef Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Hypertension control: how well are we doing? Arch Intern Med. 2003;163(22):2705–11.PubMedCrossRef
3.
Zurück zum Zitat Grant RW, Cagliero E, Dubey AK, et al. Clinical inertia in the management of Type 2 diabetes metabolic risk factors. Diabet Med. 2004;21(2):150–55.PubMedCrossRef Grant RW, Cagliero E, Dubey AK, et al. Clinical inertia in the management of Type 2 diabetes metabolic risk factors. Diabet Med. 2004;21(2):150–55.PubMedCrossRef
5.
Zurück zum Zitat O’Connor P, Sperl-Hillen J, Johnson P, Rush W, Biltz G. Clinical inertia and outpatient medical errors. In: Advances in Patient Safety: From Research to Implementation, Volume 2: Concepts and Methodology. Vol 2 (of 4). Rockville, MD: Agency for Healthcare Research and Quality; 2005:293–308. O’Connor P, Sperl-Hillen J, Johnson P, Rush W, Biltz G. Clinical inertia and outpatient medical errors. In: Advances in Patient Safety: From Research to Implementation, Volume 2: Concepts and Methodology. Vol 2 (of 4). Rockville, MD: Agency for Healthcare Research and Quality; 2005:293–308.
6.
Zurück zum Zitat O’Connor PJ. Overcome clinical inertia to control systolic blood pressure. Arch Intern Med. 2003;163(22):2677–78.PubMedCrossRef O’Connor PJ. Overcome clinical inertia to control systolic blood pressure. Arch Intern Med. 2003;163(22):2677–78.PubMedCrossRef
7.
Zurück zum Zitat Wright JT, Jr., Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293(13):1595–608.PubMedCrossRef Wright JT, Jr., Dunn JK, Cutler JA, et al. Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. JAMA. 2005;293(13):1595–608.PubMedCrossRef
8.
Zurück zum Zitat Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475–84.PubMed Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475–84.PubMed
9.
Zurück zum Zitat O’Connor P. Commentary—improving diabetes care by combating clinical inertia. Health Serv Res. 2005;40(6 Pt 1):1854–61.PubMedCrossRef O’Connor P. Commentary—improving diabetes care by combating clinical inertia. Health Serv Res. 2005;40(6 Pt 1):1854–61.PubMedCrossRef
10.
Zurück zum Zitat Shewchuk R, O’Connor SJ. Using cognitive concept mapping to understand what health care means to the elderly: an illustrative approach for planning and marketing. Health Market Q. 2002;20(2):69–88.CrossRef Shewchuk R, O’Connor SJ. Using cognitive concept mapping to understand what health care means to the elderly: an illustrative approach for planning and marketing. Health Market Q. 2002;20(2):69–88.CrossRef
11.
Zurück zum Zitat Levine DA, Saag KG, Casebeer LL, Colon-Emeric C, Lyles KW, Shewchuk RM. Using a modified nominal group technique to elicit director of nursing input for an osteoporosis intervention. Journal of the American Medical Directors Association 2006;7(7):420–5.PubMedCrossRef Levine DA, Saag KG, Casebeer LL, Colon-Emeric C, Lyles KW, Shewchuk RM. Using a modified nominal group technique to elicit director of nursing input for an osteoporosis intervention. Journal of the American Medical Directors Association 2006;7(7):420–5.PubMedCrossRef
12.
Zurück zum Zitat Schiffman S, Reynolds M, Young F. Introduction to Multidimensional Scaling. New York: Academic Press; 1981. Schiffman S, Reynolds M, Young F. Introduction to Multidimensional Scaling. New York: Academic Press; 1981.
13.
Zurück zum Zitat Aldenderfer M, Blashfield R. Cluster Analysis. Beverly Hills, CA: Sage Publications; 1984. Aldenderfer M, Blashfield R. Cluster Analysis. Beverly Hills, CA: Sage Publications; 1984.
14.
Zurück zum Zitat Kruskall J, Wish M. Multi-Dimensional Scaling. Newbury Park, NJ: Sage Publications; 1990. Kruskall J, Wish M. Multi-Dimensional Scaling. Newbury Park, NJ: Sage Publications; 1990.
15.
Zurück zum Zitat Speece D. Methodological issues in cluster analysis: how clusters become real. In: Learning disabilities: Theoretical research issues. Hillsdale, NJ: Erlbaum; 1990:210–213. Speece D. Methodological issues in cluster analysis: how clusters become real. In: Learning disabilities: Theoretical research issues. Hillsdale, NJ: Erlbaum; 1990:210–213.
16.
Zurück zum Zitat Joseph F, Hair J, Anderson RE, Tatham RL, Black WC. Multivariate Data Analysis. 5th ed. Upper Saddle River, NJ: Prentice-Hall, Inc.; 1998. Joseph F, Hair J, Anderson RE, Tatham RL, Black WC. Multivariate Data Analysis. 5th ed. Upper Saddle River, NJ: Prentice-Hall, Inc.; 1998.
17.
Zurück zum Zitat Pickering TG. White coat hypertension: time for action. Circulation. 1998;98(18):1834–36.PubMed Pickering TG. White coat hypertension: time for action. Circulation. 1998;98(18):1834–36.PubMed
18.
Zurück zum Zitat Kerr EA, Smith DM, Hogan MM, et al. Building a better quality measure: are some patients with ‘poor quality’ actually getting good care? Med Care. 2003;41(10):1173–82.PubMedCrossRef Kerr EA, Smith DM, Hogan MM, et al. Building a better quality measure: are some patients with ‘poor quality’ actually getting good care? Med Care. 2003;41(10):1173–82.PubMedCrossRef
19.
Zurück zum Zitat Goodwin JS. Embracing complexity: a consideration of hypertension in the very old. J Gerontol Ser A Biol Sci Med Sci. 2003;58(7):653–8. Goodwin JS. Embracing complexity: a consideration of hypertension in the very old. J Gerontol Ser A Biol Sci Med Sci. 2003;58(7):653–8.
20.
Zurück zum Zitat Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716–24.PubMedCrossRef Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716–24.PubMedCrossRef
21.
Zurück zum Zitat Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. The vector model of complexity. J Gen Intern Med. 2007;22(s9). Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. The vector model of complexity. J Gen Intern Med. 2007;22(s9).
23.
Zurück zum Zitat Casalino LP, Alexander GC, Jin L, Konetzka RT. General internists’ views on pay-for-performance and public reporting of quality scores: a national survey. Health Aff (Millwood). 2007;26(2):492–9.CrossRef Casalino LP, Alexander GC, Jin L, Konetzka RT. General internists’ views on pay-for-performance and public reporting of quality scores: a national survey. Health Aff (Millwood). 2007;26(2):492–9.CrossRef
Metadaten
Titel
Reasons for Not Intensifying Medications: Differentiating “Clinical Inertia” from Appropriate Care
verfasst von
Monika M. Safford, MD
Richard Shewchuk, PhD
Haiyan Qu, PhD
Jessica H. Williams, MPH
Carlos A. Estrada, MD, MS
Fernando Ovalle, MD
Jeroan J. Allison, MD, MSc
Publikationsdatum
01.12.2007
Verlag
Springer-Verlag
Erschienen in
Journal of General Internal Medicine / Ausgabe 12/2007
Print ISSN: 0884-8734
Elektronische ISSN: 1525-1497
DOI
https://doi.org/10.1007/s11606-007-0433-8

Weitere Artikel der Ausgabe 12/2007

Journal of General Internal Medicine 12/2007 Zur Ausgabe

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.