Clinical inertia or clinical uncertainty?: Factors associated with lack of medication intensification in response to elevated blood pressure.

Background: Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied. Objective: We examined the process of care for diabetic patients with elevated triage blood pressure (≥140/90 mm Hg) during routine primary care visits to assess 1) whether a treatment change occurred; 2) and to what degree specific patient and provider factors correlated with the likelihood of treatment change. Design: Prospective cohort study. Setting: 9 Department of Veterans Affairs facilities in 3 midwestern states. Participants: 1169 diabetic patients with scheduled primary care visits to 92 primary care providers between February 2005 and March 2006. Measures: Proportion of patients undergoing blood pressure treatment change (medication intensification or planned follow-up within 4 weeks). Predicted probability of treatment change from a multi-level logistic model that included variables assessing clinical uncertainty, competing demands and prioritization, and medication related factors (controlling for blood pressure). Results: Overall, 573 (49%) patients had a blood pressure treatment change at the visit. The following factors made treatment change less likely: repeat blood pressure by provider recorded as < 140/90 mm Hg (13% vs. 61%, p<0.001); patient report of home blood pressure < 140/90 mm Hg (18% vs. 52%, p<0.001); provider systolic blood pressure goal >130 mm Hg (33% vs. 52%, p=0.002); discussion at the visit of conditions unrelated to hypertension and diabetes (44% vs. 55%, p= 0.008); and discussion of medication issues (23% vs. 52%, p<0.001). Limitations: Providers knew that the study pertained to diabetes and hypertension and treatment change was assessed for one visit per patient. Conclusions: Approximately 50% of diabetic patients presenting with a substantially elevated triage blood pressure received treatment change at the visit. Clinical uncertainty about the true blood pressure value was a prominent reason for providers not intensifying therapy.

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