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CME / ABIM MOC / CE

Does Therapeutic Inertia Play a Role in Racial Differences in Blood Pressure Control?

  • Authors: News Author: Sue Hughes; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 2/25/2022
  • Valid for credit through: 2/25/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for primary care physicians, cardiologists, nephrologists, nurses, pharmacists and other members of the healthcare team who care for patients with hypertension.

The goal of this activity is to assess whether race resulted in therapeutic inertia in a major hypertension study.

Upon completion of this activity, participants will:

  • Distinguish variables that affect the risk for therapeutic inertia among patients with hypertension
  • Assess whether race plays a role in therapeutic inertia in a large study of patients with hypertension
  • Outline implications for the healthcare team


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News Author

  • Sue Hughes

    Journalist
    Medscape Medical News

    Disclosures

    Disclosure: Sue Hughes has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/CME Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

CME/CE Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Does Therapeutic Inertia Play a Role in Racial Differences in Blood Pressure Control?

Authors: News Author: Sue Hughes; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/25/2022

Valid for credit through: 2/25/2023

processing....

Clinical Context

Therapeutic inertia is defined as the failure of clinicians to adjust treatment to reach therapeutic goals, and it is a common phenomenon in cases of chronic illnesses such as diabetes and hypertension. Bolen and colleagues specifically examined the prevalence of therapeutic inertia for hypertension and underlying risk factors for therapeutic inertia in a cohort study published in the May 2008 issue of the Journal of General Internal Medicine.[1]

Researchers identified 254 patients with hypertension and diabetes in one academically affiliated managed care program in the United States. Over a 2-year period, there were 1374 clinical encounters in which the patients’ blood was elevated (systolic blood pressure [SBP] ≥ 140 mm Hg or diastolic blood pressure [DBP] ≥ 90 mm Hg). Antihypertensive intensification occurred at just 13% of these visits.

Variables associated with higher rates of intervention for elevated blood pressure (BP) included a visit with the patient’s usual primary care provider and routine visits for follow-up of chronic illness. The presence of coronary heart disease and blood glucose level > 150 mg/dL were associated with higher rates of therapeutic inertia, as was comanagement of the patient with a cardiologist.

Could higher rates of therapeutic inertia help explain worse control of BP among Black and Hispanic patients with hypertension? The current study by Zheutlin and colleagues addresses this question.

Study Synopsis and Perspective

Therapeutic inertia regarding intensification of BP treatment has been shown to be more of an issue in Black patients, but this was not the case in the Systolic Blood Pressure Intervention Trial (SPRINT) trial, which involved a strict standardized approach to BP management, a new analysis shows.

"Overall, we found that therapeutic inertia was similar in different races in the SPRINT trial. We did not see disparities that have been reported in previous observational studies," lead author, Alexander Zheutlin, MD, University of Utah School of Medicine, Salt Lake City, told theheart.org | Medscape Cardiology.

"These results show that a well-resourced approach in which a standardized approach to blood pressure measurement and treatment intensification is followed can overcome the racial disparity that is seen in therapeutic inertia and the treatment of blood pressure,” he added.

The study was published January 4 in JAMA Network Open.[2]

The authors explained that hypertension remains a leading modifiable cause of racial disparities in cardiovascular disease. Despite similar treatment rates and increased availability of safe, effective, and affordable antihypertensive medications, BP control rates among Black and Hispanic adults remain significantly lower than among White adults in the United States, and one of the factors contributing to this is thought to be therapeutic inertia -- the phenomenon of clinicians not initiating or up-titrating clinically indicated therapy in the setting of unmet treatment goals.

The current analysis of the SPRINT trial was conducted to investigate whether racial and ethnic differences in therapeutic inertia in hypertension were present when BP care was standardized and protocolized.

The landmark SPRINT trial compared intensive (< 120 mm Hg) with standard (< 140 mm Hg) SBP treatment goals in adults aged 50 years and older at high risk for cardiovascular disease. The present analysis was restricted to participant visits with measured BP above the target goal and included 4141 patients in the standard group and 4415 patients in the intensive group.

Results showed that the overall prevalence of therapeutic inertia -- defined as no antihypertensive medication intensification at each study visit where the BP was above target goal -- was either similar or lower for Black and Hispanic participants than for White participants. This pattern was observed whether participants were randomly assigned to the standard or intensive treatment group.

"These findings support the idea that a standardized approach to blood pressure management, as implemented in SPRINT, may help ensure equitable care is provided to all patients and could reduce the contribution of therapeutic inertia to disparities in uncontrolled blood pressure," the authors said.

They pointed out that therapeutic inertia has been identified as a key clinician-level barrier to BP control and is estimated to be present in more than 80% of clinic visits in community practice whereas in the current analysis of the SPRINT trial, therapeutic inertia was present in 50% to 60% of participant visits with uncontrolled BP.

"In SPRINT, blood pressure had to be measured at defined intervals with a specific method, and there were clear instructions on intensifying treatment if blood pressure was above a certain goal," Zheutlin noted. "Our results show that within such strict confines, therapeutic inertia does not seem to be different between different racial groups. This suggests that we could make better gains in blood pressure control and more equitable treatment if we adopted a standardized approach to hypertension management."

He added: "Many guidelines have been published on when to start treatment and the targets for blood pressure, but there is a lot of variation in how we turn these guidelines into protocols. We need to bring in more consistent protocols on blood pressure measurement and intensification, and ensure they are followed. In practice, if the BP is 5 or 10 mm Hg above target, a clinician may defer a decision to intensify treatment and intensification never gets done. But if there was a strict protocol to follow there would be less chance of this happening."

Therapeutic Inertia Still High

In an accompanying commentary,[3] Matthew Rivara, MD, Nisha Bansal, MD, and Bessie Young, MD, University of Washington, Seattle, Washington, said the current SPRINT analysis has broad implications for reducing racial and ethnic disparities in achievement of evidence-based treatment targets in the general population.

"In hypertension management, standardized protocols for medication adjustments may limit clinician practice heterogeneity to ultimately reduce differences in blood pressure control among racial and ethnic minority populations," they wrote, but they added that such protocols must be implemented thoughtfully to incorporate individualized clinical assessment and clinician-patient shared decision making.

Rivara et al pointed out that the rates of therapeutic inertia in SPRINT, although lower than community-based estimates, were still very high. They suggested reasons for this could include clinician concerns about medication efficacy, adverse effects, and patient mistrust of medical professionals. Outside the clinical trial environment, additional considerations may include prescription drug and laboratory test costs, pharmacy access, and competing demands during busy clinic visits.

To address these challenges, they said that clinicians need education on current clinical practice guidelines, how to manage complications of intensified antihypertensive therapies, and training on shared decision making, including culturally sensitive collaborative care. Similarly, care systems must support patients on how to address concerns about treatments.

Finally, further research is needed to better define the specific factors associated with therapeutic inertia to allow tailored interventions to overcome this inertia.

"In designing and performing such research, it is vital that investigators engage with racial and ethnic minority groups to better explore the intersection of race, ethnicity, therapeutic decision-making, trust, and shared decision-making," they added.

The SPRINT trial was funded with federal funds from the National Institutes of Health (NIH). Zheutlin reported receiving grants from the NIH during the conduct of the study.

Study Highlights

  • Investigators drew study data from SPRINT, which enrolled patients aged ≥ 50 years with high cardiovascular risk and SBP between 130 mm Hg and 180 mm Hg. They randomly assigned participants to target SBP levels < 120 or < 140 mm Hg. The trial demonstrated that stricter BP control was associated with improved cardiovascular and mortality outcomes.
  • Researchers followed participants in SPRINT monthly for 3 months and then every 3 months thereafter. Clinicians were instructed to augment antihypertensive therapy at these visits until the target SBP was achieved.
  • Participant race/ethnicity data was derived from self-report. The current study compares rates of therapeutic inertia among White, Hispanic, and Black participants.
  • Therapeutic inertia was defined as the failure to augment antihypertensive therapy to goal at a study visit.
  • Researchers adjusted the main study result to account for sociodemographic variables, baseline values of clinical measurements, prior therapeutic inertia, and treatment-related serious adverse events.
  • The study analysis included 8556 participants. The median age of participants was 67 years, and 35.4% of participants were women.
  • 59.2% of participants were White, whereas 31.5% and 9.3% were Black and Hispanic, respectively.
  • Compared with White participants, Hispanic and Black participants were younger, more likely to be female, and represented higher proportions of individuals without a usual source of health care and who were not receiving a statin or aspirin.
  • In the standard treatment group (goal SBP < 140 mm Hg), the crude rates of therapeutic inertia in the White, Black, and Hispanic cohorts were 59.8%, 56.8%, and 59.7%, respectively.
  • For the standard treatment group, the odds ratio (OR) for therapeutic inertia in comparing the Black and White cohorts was 0.85 (95% CI: 0.79, 0.92). The respective OR in comparing the Hispanic and White cohorts was 1 (95% CI: 0.9, 1.13).
  • In the intensive treatment group (goal SBP < 120 mm Hg), the crude rates of therapeutic inertia in the White, Black, and Hispanic cohorts were 56%, 54.5%, and 51%, respectively.
  • For the intensive treatment group, the OR for therapeutic inertia in comparing the Black and White cohorts was 0.94 (95% CI: 0.88, 1.01). The respective OR in comparing the Hispanic and White cohorts was 0.89 (95% CI: 0.79, 1).
  • The risk for therapeutic inertia increased during the study period in all racial/ethnic groups.
  • Variables associated with higher rates of therapeutic inertia included older age, therapeutic inertia at previous appointments, and the use of thiazide diuretics. These risk factors were generally similar regardless of race/ethnicity.

Clinical Implications

  • In a previous study by Bolen and colleagues, therapeutic inertia for hypertension was evident in 87% of visits featuring elevated BP. Variables associated with higher rates of intervention for elevated BP included a visit with the patient’s usual primary care provider and routine visits for follow-up of chronic illness. The presence of coronary heart disease and blood glucose level > 150 mg/Dl were associated with higher rates of therapeutic inertia, as was co-management of the patient with a cardiologist.
  • In the current study by Zheutlin and colleagues, therapeutic inertia was similar or slightly reduced among Black and Hispanic participants in the SPRINT trial vs White participants. This was true in both the intensive and standard SBP control cohorts.
  • Outline implications for the healthcare team: The healthcare team should consider target-based therapy for BP control to reduce race-based disparities in the care of hypertension.

 

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