Clinical Inertia in the Diagnosis and Management of Hypertension Following Ambulatory Blood Pressure Monitoring

BACKGROUND: Clinical inertia is common after office blood pressure (BP) is high. Little is known about clinical inertia after ambulatory BP monitoring (ABPM). METHODS: This was an electronic health record-based retrospective cohort study of patients with high office BP (≥140/90 mm Hg) referred for ABPM at a medical center in New York City between 2016 and 2020. Diagnostic inertia was defined as clinicians not newly diagnosing or treating hypertension in patients with high ABPM (i.e., mean awake BP ≥135/85 mm Hg). Therapeutic inertia was defined as clinicians not intensifying treatment for patients with established hypertension after high ABPM. Multilevel modeling was used to assess patient and clinician characteristics associated with inertia. RESULTS: Among 329 patients without prior hypertension, 144 (44%) had high awake BP. Of these, diagnostic inertia occurred in 45 of 144 (31%). Among 239 patients taking antihypertensive medication, 141 (59%) had high awake BP. Of these, therapeutic inertia occurred in 73 of 141 (52%). In multilevel models, male gender (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.11-7.08), lower awake systolic BP (SBP) (OR 0.73 per 5 mm Hg increase, 95% CI 0.53-1.00), and specialist vs. primary care clinician type (OR 4.57, 95% CI 1.78-11.75) were associated with increased diagnostic inertia. Increasing age (OR 1.16 per 5-year increase, 95% CI 1.00-1.28) and lower awake SBP (OR 0.82 per 5 mm Hg increase, 95% CI 0.66-0.95) were associated with increased therapeutic inertia. CONCLUSIONS: Diagnostic and therapeutic inertia were common after ABPM, particularly when awake SBP was near the threshold.