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Reasons for not intensifying medications: differentiating "clinical inertia" from appropriate care
Monika M Safford1, Richard Shewchuk, Haiyan Qu
1University of Alabama at Birmingham, Birmingham, AL, USA. msafford@uab.edu
Insights
Physician inaction on uncontrolled blood pressure, termed clinical inertia, may often be appropriate care, not a quality issue. Understanding these reasons helps improve quality measurement.
Area of Science:
- Cardiology
- Health Services Research
- Medical Quality Improvement
Background:
- Clinical inertia, or physician inaction with uncontrolled risk factors like high blood pressure, is a potential quality problem.
- It is estimated to contribute to a significant portion of cardiovascular events.
- The underlying reasons for clinical inertia remain poorly understood.
Purpose of the Study:
- To develop an empirically based conceptual model of clinical inertia from the physician's viewpoint.
- To differentiate clinical inertia from other forms of clinical inaction.
Main Methods:
- Nominal Group panels of practicing physicians were convened.
- Physicians identified reasons for not intensifying blood pressure medications in patients with uncontrolled readings.
- Multidimensional scaling and hierarchical cluster analysis were used to model physician perspectives.
Main Results:
- High agreement among physicians on reasons for inaction indicated data saturation.
- A cognitive map was developed, representing an empirically derived model of clinical inaction.
- The model suggests that much physician inaction may represent appropriate clinical care.
Conclusions:
- Physician reasons for not intensifying medications indicate that low intensification rates may not always signify poor quality of care.
- The derived model can guide the development of performance measures for clinical inertia.
- Improved measures can better identify true quality of care issues.
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.
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