Should Primary Care Physicians Be Managing Hypertension?

“It’s time to overcome clinical inertia.” It seems as if every article describing therapeutic inertia and suboptimal blood pressure control is accompanied by such an editorial.1–3 Prior to 2000, most clinicians would not have understood this. The then current understanding of uncontrolled hypertension, as well described in the 1988 Joint National Committee report, was that “failure to make life-style changes and take medications as instructed as the two most common factors impeding effective therapy.” Poor blood pressure control was the patient’s fault. Building on our work demonstrating frequent failures to intensify medications in the setting of inadequate blood pressure control,4 and his own analyses of diabetes care, Phillips in 2001 coined the term clinical (or therapeutic) inertia.5 This revolutionized how we think about uncontrolled hypertension and subsequent studies confirmed that therapeutic inertia pervades hypertension care.6,7 Armed with this new paradigm for understanding uncontrolled hypertension, initiatives guided by the National High Blood Pressure Education Program drove improvement efforts. Dramatic improvements in hypertension control were seen, and by the end of the decade, leaders in care such as Chobanian could claim “cause for some celebration.”8 Yet something happened in the subsequent decade. These impressive improvements in blood pressure control were not sustained.9 Reasons are not entirely clear but it is not explained by worsening access to care. Instead, there is evidence of declining quality of care including decreased awareness, treatment, and treatment effectiveness of hypertension.10 Use of monotherapy among people with hypertension increased despite an increasing prevalence of factors associated with treatment resistance such as obesity and diabetes. And, as illustrated by Hiura et al. in this issue of the American Journal of Hypertension,11 and other recent articles,12 therapeutic inertia remains widespread. After 20+ years of saying we must overcome therapeutic inertia, little progress seems to have been made. Also concerning in the report by Hiura is that an intervention directed at improving physicians’ hypertension care had minimal impact on therapeutic inertia; information on blood pressure control was not available. This intervention, the American Medical Association Measure Accurately, Act Rapidly, and Partner with Patients Blood Pressure (MAP BP) program provides feedback to clinicians on measures including the percentage of patients with controlled blood pressure, change in systolic blood pressure after treatment intensification, and a measure of treatment intensity.13 Another evaluation of MAP BP did demonstrate impressive improvements in blood pressure control.14 However, the level of therapeutic inertia at baseline in this other study was much lower than in Hiura’s report, and implementation of MAP BP was accompanied by extensive facilitation and protocol-guided escalation of medications. The extent to which such facilitation was utilized in the current study is uncertain. So here we are in 2024; there is still widespread therapeutic inertia and national blood pressure control is well-below where we would want it, and where it was several years ago. Perhaps it is time to conclude that more of the same will not be sufficient. Should we be considering different models of care? Perhaps it is even time to ask whether primary care physicians should be the principal managers of treatment intensification among people with elevated blood pressure. If we are even to consider such a dramatic alternative, there are several questions we should address. First, does therapeutic inertia really exist? It has been suggested that rather than being simple inaction in the face of elevated blood pressure, it could represent thoughtful uncertainty of the “true” blood pressure and competing priorities for care.15 Treating to a specific goal blood pressure could also raise concerns as the incremental benefits of intensifying therapy when near that threshold may be small. Yet studies have shown that inertia may occur despite multiple elevated blood pressures and physicians often state they are satisfied with elevated blood pressures.16 Phillips suggested in 2001 that there are many “soft” reasons for inertia.5 I see this in my practice. The systolic blood pressure is elevated, and excuse-seeking begins. My patient will volunteer a reason, such as traffic on driving in, rushing in from the parking lot, or forgetting to take their morning medications. Too often, I will concur and say we will recheck next time. The end-result is many months of inadequate control. Therapeutic inertia certainly exists but the extent to which it may represent thoughtful uncertainty has not yet been completely defined. Second, should we even care about therapeutic inertia? From a quality improvement perspective, following the well-known Donabedian model, we should be focusing on those processes that are strongly linked to important patient outcomes. There have been many observational studies establishing this link; more therapeutic inertia is associated with worse blood pressure control4,6,17 and in one article also with increased rates of myocardial infarction.18 Thus, we would expect that interventions focusing on reducing therapeutic inertia would produce the desired result of better blood pressure control. Third, does a reasonable alternative to primary care provider management exist? In overcoming therapeutic inertia, the decision on intensifying therapy is central. While many different models of care exist, and sharing of care responsibilities among different health professionals is increasingly the norm, in most models the primary care provider retains control over medications. Many studies have shown, though, the benefits of pharmacist or nurse-based interventions, and a meta-analysis demonstrated the greatest reductions in systolic blood pressures are seen with team-based care in which medication titration is performed by a nonphysician.19 The success of such models goes back over 50 years, and some may recall the pride with which Perry described his VA clinics in which nurses followed rigid stepped-care protocols and physicians provided minimal oversight.20 It may be that nonphysicians are just more willing, on average, to accept protocol driven care targeting specific thresholds. In his writing on overcoming clinical inertia, Phillips suggested “every occurrence of blood pressure above goal should prompt intensification of therapy unless contraindicated” and “run the numbers first.”3 While I am not entirely comfortable with this approach, I, along with many other primary care providers, may need to adopt more of this attitude to ensure best outcomes for our patients. Otherwise, we may find that, more and more, decisions on intensifying therapy are handed to nonphysician team members. This may have advantages in that it would free up time for other critical aspects of primary care. Yet, I think being relieved of medication management for hypertension would be unfortunate, but 20+ years of therapeutic inertia are enough. The author declared no conflict of interest.