Treatment Intensification in a Hypertension Telemanagement Trial

Abstract

Abstract-Clinical inertia represents a barrier to hypertension management. As part of a hypertension telemanagement trial designed to overcome clinical inertia, we evaluated study physician reactions to elevated home blood pressures. We studied 296 patients from the Hypertension Intervention Nurse Telemedicine Study who received telemonitoring and study physician medication management. When a patient's 2-week mean home blood pressure was elevated, an "intervention alert" prompted study physicians to consider treatment intensification. We examined treatment intensification rates and subsequent blood pressure control. Patients generated 1216 intervention alerts during the 18-month intervention. Of 922 eligible intervention alerts, study physicians intensified treatment in 374 (40.6%). Study physician perception that home blood pressure was acceptable was the most common rationale for nonintensification (53.7%).When "blood pressure acceptable" was the reason for not intensifying treatment, the mean blood pressure was lower than for intervention alerts where treatment intensification occurred (135. Previous studies provide evidence for improved BP control using telemanagement models in selected patient populations. [11][12][13] Compared with clinic BP measurement, home telemonitoring may also better predict cardiovascular risk and is less subject to observer bias (white-coat hypertension and masked hypertension). 14 -18 The Hypertension Intervention Nurse Telemedicine Study (HINTS) was an 18-month randomized, controlled trial designed to circumvent factors contributing to clinical inertia. 19 We examined data from the medication management arms of HINTS to determine how physicians reacted to elevated BP values, why they reacted as they did, and how their decisions impacted subsequent patient BP control after episodes of elevated BP. Our goal was to determine whether clinical inertia persisted in HINTS despite the efforts to overcome it. Methods HINTS DesignHINTS randomized 593 eligible veterans into 4 groups: (1) a nurse-administered behavioral management intervention; (2) a nurse-administered, physician-directed medication management intervention using a validated clinical decision support system; (3) a combined behavioral management and medication management intervention; and (4) usual care. Eligible patients received primary care at the Durham Veterans Affairs Medical Center, had a diagnosis of hypertension, used BP-lowering medication, and had inadequate BP control (Ͼ140/90 mm Hg for all patients) based on the average of the previous 12 months' clinic BP measurements obtained from electronic medical charts. Exclusion criteria were receipt of dialysis; a serum creatinine Ͼ2.5 or no documentation of renal function; history of organ transplant; hospitalization for stroke, myocardial infarction, or coronary artery revascularization within 3 months of contact; diagnosis of metastatic cancer or dementia; lack of a home telephone; residence in a nursing home; receipt of home health care; or severely impaired hearing ...

Racial Differences in the Effect of a Telephone-Delivered Hypertension Disease Management Program

“…As described in the methods section, the behavioral intervention, which was combined with medication management in the combined arm, covered many of the psychosocial and disease-perception issues that may impact blood pressure control. Further, it has been previously reported, using HINTS data, that patient race was not associated with study physicians' deciding to intensify medication regimens, 15 indicating that results in this paper were not the result of differing medication treatment decisions. The combination of the medication management and addressing psychosocial factors related to hypertension may have impacted different issues among African American and white patients.…”

“…14 The study physician reviewed the patient's BP, medication, and adherence (based on patient report and prescription refill data) with the nurse and decided whether to change hypertension medication. 15 The nurse communicated recommended changes to the patient, while the study physician electronically prescribed the medication and generated a note in the patient's medical record that was co-signed by the patient's primary care provider. The nurse called the patient 3 weeks after the medication change to obtain reports of adverse effects and address patient questions.…”

The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review

“…conclude their work on hypertension telemanagement with: “ However, when physicians did not intensify treatment, it was because blood pressure was closer to an acceptable threshold, and repeat blood pressure elevations occurred less frequently. Failure to intensify treatment when home blood pressure is elevated may, at times, represent good clinical judgment, not clinical inertia ” [41], and Kennedy and Mac Lean stated: “ It is important to distinguish clinical inertia from modified therapeutic goals ” [45]. …”

Factors associated with clinical inertia: an integrative review

“…Moreover, gender disparities are reported by some, with women more likely to suffer than men as a result of clinical inertia with regard to the prevention of cardiovascular disease 27,28. However, other studies report no evidence of gender issues in relation to clinical inertia,29 so the evidence is inconsistent. Last but not least, limited reimbursement, socioeconomic and cultural disparity in terms of affordability or acceptability of a prescribed treatment, or lack of health care availability for underserved populations are all significant barriers to treatment modification according to guidelines 6,17,18…”