Promoters of Therapeutic Inertia in Managing Hypertension: A Consensus-Based Study

ABSTRACT

Objectives: Hypertension is among the most commonly managed diseases in general practice. Therapeutic inertia could be responsible for the vast majority of cardiovascular events in patients with hypertension. The present study was conducted to explore views and opinions of clinicians involved in providing health care services to patients with hypertension in Palestine and achieve formal consensus on promoters of the phenomenon of therapeutic inertia from their point of view.

Study Design: In this exploratory study, a mixed-methods approach combining literature search, qualitative interviews, and 2 Delphi technique rounds was used.

Methods: Interviews with key contact clinicians (n = 18) were conducted. To achieve formal consensus on promoters of therapeutic inertia in hypertension, 2 Delphi rounds were conducted using a panel of general practitioners, family medicine specialists, and internal medicine specialists (n = 50).

Results: The majority of the panel members (90%) agreed that therapeutic inertia was prevalent in treating patients with hypertension in Palestine. Of the 41 potential promoters, consensus was achieved on 37 (90.2%). Of these 37 promoters, 21 (56.8%) were clinician-related, 10 (27.0%) were patient-related, and 6 (16.2%) were health care system–related factors. The study explored views and opinions of clinicians involved in providing health care services to patients with hypertension in Palestine relevant to therapeutic inertia in hypertension.

Conclusions: Findings of this study could inform policy and decision makers to devise strategies to eliminate or reduce therapeutic inertia in managing hypertension in Palestinian clinical practice. Future studies are needed to determine whether such strategies can improve outcomes of patients with hypertension.

Am J Manag Care. 2021;27(11):480-486. https://doi.org/10.37765/ajmc.2021.88775

Takeaway Points

We identified consensus-based promoters of clinical inertia in managing hypertension. Policy makers should address these promoters to improve health-related outcomes in hypertension.

• Therapeutic inertia can be responsible for the majority of cardiovascular events.
• Promoters of clinical inertia may vary among health care systems.
• Consensus was achieved on 37 promoters of clinical inertia in managing hypertension.

In clinical practice, hypertension is one of the most commonly encountered and managed health conditions.^1,2 According to some estimates, there are more than 1.38 billion individuals with hypertension around the world.³ In Palestine, hypertension is very common in adults, with an estimated prevalence rate of around 27.6%.⁴

Recent studies have identified initiating, modifying, and intensifying pharmacotherapy of hypertension as gaps that need to be bridged in evidence-based practice.^5-8 Although guidelines for evidence-based management of hypertension are available, devising individualized pharmacotherapeutic plans for patients can be hindered by humanistic factors related to the health care provider, the patient receiving pharmacotherapy, or the infrastructure of the health care system.^9-18 As a result, many patients fail to attain their therapeutic goals. Although many factors could be contributing to this failure, therapeutic inertia has been highlighted as one of the most significant contributors.^19,20

Therapeutic inertia, clinical inertia, or physician inertia is a phenomenon in which clinicians fail to manage at least 1 patient condition as a result of lack of adequate intervention.¹⁹ Therapeutic inertia has been recognized in the management of certain chronic conditions for which algorithms and pharmacotherapeutic objectives have been well established, including hypertension, dyslipidemia, diabetes, arthritis, osteoporosis, and gout.^7,19,21-25

Findings of previous studies have shown that therapeutic inertia in hypertension was highly prevalent in various health care systems.²⁶ The burden of therapeutic inertia in certain health conditions could be severe. It has been estimated that therapeutic inertia could be responsible for the vast majority (up to 80%) of cardiovascular accidents.^27,28 Optimal control of blood pressure reduced mortality rates from coronary heart disease and cerebrovascular disease by 20% and 24%, respectively.²⁶ Therefore, therapeutic inertia should be eliminated to achieve optimal control of blood pressure and other pharmacotherapeutic goals in patients with hypertension.^29,30

Pharmacotherapy is within the purview of clinicians. The literature does not narrate intensively the promoters of therapeutic inertia from the point of view of clinicians involved in providing health care services to patients with hypertension. To reduce therapeutic inertia in hypertension and improve control of blood pressure, understanding what promotes therapeutic inertia in managing hypertension could be of great importance. Identifying and understanding promoters of therapeutic inertia in hypertension might be essential for devising effective interventions to address therapeutic inertia and improve patient outcomes.^16,18

Previous studies have identified some potential promoters of therapeutic inertia.^18,31,32 However, little is known about whether these promoters would be formally accepted by clinicians involved in providing health care services to patients with hypertension in Palestine. Therefore, this exploratory study was conducted to explore views and opinions of such clinicians with regard to therapeutic inertia and to achieve formal consensus on promoters of the phenomenon in managing hypertension in Palestinian clinical practice from their point of view. Such consensus-based promoters might be targeted with future interventional strategies to eliminate or reduce the phenomenon and improve outcomes of patients with hypertension in Palestine.

METHODS

Study Design

In this exploratory study, a mixed-methods approach combining literature search, interviews with experts, and a 2-round Delphi technique was used.^18,33-44 This study is reported in adherence to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist.45 Adherence to the COREQ checklist is shown in eAppendix A (eAppendices available at ajmc.com).

Collection of Potential Promoters of Therapeutic Inertia

An extensive literature search was performed to collect promoters of therapeutic inertia in hypertension that were published in previous research. Results of the literature search were reported separately.

The interviews with clinicians were conducted privately in their places of work to explore their views and opinions on therapeutic inertia and what factors promoted the phenomenon in Palestinian clinical practice from their point of view.¹⁸ Key contacts—clinicians who were general practitioners in primary care (n = 5), family medicine specialists (n = 6), and internal medicine specialists (n = 7)—were contacted and interviewed on their views on therapeutic inertia in hypertension and factors that promoted the phenomenon in the Palestinian context. During the interviews, clinicians were asked open-ended questions to extract their views and opinions on the prevalence of therapeutic inertia and the factors they thought promoted therapeutic inertia in managing hypertension in Palestine. Factors identified through the literature and those mentioned by the clinicians during the interviews were compiled into a list.

The Delphi Technique

Formal consensus among the panel of clinicians on promoters of therapeutic inertia in managing patients with hypertension in Palestinian clinical practice was sought using the Delphi technique.^46-48

The Panel

A panel of clinicians who were involved in providing health care services to patients with hypertension in Palestinian clinical practice was formed. A judgmental sampling technique was utilized to identify, approach, invite, consent, and recruit the clinicians to the panel. Candidate clinicians were identified through key contacts in clinical practice. The design and aims of this exploratory study were explained to the candidate panelists by the field researchers. The following inclusion criteria were used to identify and recruit candidate clinicians to the panel: (1) having a formal license to practice medicine in Palestine, (2) being affiliated with a main health care facility providing health care services for patients with hypertension, (3) caring for at least 5 patients with hypertension per week, and (4) having experience of at least 5 years in providing health care services for patients with hypertension in Palestine. All panelists were clinicians who provided health care services for patients with hypertension in Palestine. We purposefully recruited only clinicians who were legally permitted to prescribe antihypertensive pharmacotherapy for patients with hypertension. The clinicians were invited from 10 different sites.

The Study Tool

The study tool used was a paper-based questionnaire that contained 3 separate parts. The first part collected the sociodemographic and practice variables of the panelists, including age, gender, number of years in clinical practice, and specialty. The second part contained questions to which clinicians had to respond with either disagree (no), neutral, or agree (yes). These questions were on (1) prevalence of therapeutic inertia in managing patients with hypertension in Palestinian clinical practice; (2) whether more efforts were needed to eliminate the phenomenon of therapeutic inertia in managing hypertension in Palestinian clinical practice; (3) whether the clinician was ever invited to attend a training, workshop, symposium, or lecture on therapeutic inertia; (4) whether guidelines or recommendations to reduce or eliminate therapeutic inertia in managing hypertension in Palestinian clinical practice existed; and (5) whether such guidelines or recommendations were needed to reduce therapeutic inertia in managing hypertension in Palestinian clinical practice. Part 3 contained the list of potential promoters collected from the search and those identified during the interviews with the key clinicians. The study tool is provided in eAppendix B. The study tool was piloted for clarity, comprehensibility, and readability by 5 clinicians.

The Iterative Delphi Rounds

Formal consensus was sought on promoters of therapeutic inertia in managing hypertension in Palestinian clinical practice using 2 iterative rounds of the Delphi technique among a panel of clinicians involved in providing health care services to patients with hypertension in Palestinian clinical practice.

The First Round

The clinicians responded to the study tool by providing their sociodemographic and practice variables in the first section. The clinicians also responded to the questions relevant to therapeutic inertia in the second part by either disagree (no), neutral, or agree (yes). In part 3, the clinicians rated each listed factor using a Likert scale of 1 to 9. After each factor, a space was provided for qualitative comments meant to justify or qualify the rating provided by the clinicians.

Analysis of the Ratings

Definitions of consensus were informed by those used in previous studies.^18,33-44 Ratings of the panelists on each factor were incorporated into an Excel spreadsheet (Microsoft Inc). The descriptive statistics—first quartile, median, third quartile, and the interquartile range (IQR)—were calculated using Excel’s statistical and computational functions. In this study, the definitions of consensus were as follows: (1) consensus to exclude the factor from the final list of promoters of therapeutic inertia in managing hypertension in Palestinian clinical practice, when the median of the ratings fell within the range of 1 to 3 and the IQR was less than or equal to 2; (2) consensus to include the factor in the final list, when the median of the ratings fell within the range of 7 to 9 and the IQR was less than or equal to 2; and (3) equivocal, when the median of the ratings fell within the range of 4 to 6 and/or the IQR was more than 2. We decided a priori to consider all equivocal factors in a second round.

The Second Round

All equivocal factors in the first round were considered in the second round. In this round, the considered factors were included in a revised study tool and given to the clinician for reconsideration. For each equivocal factor, the clinicians were provided with the following information: (1) a reminder of the clinician’s own rating in the first round, (2) the median of the ratings and IQR of all clinicians, and (3) summary of comments provided by the clinicians to justify or qualify their rating. The clinicians were asked if they wanted to reconsider their opinions after reviewing the information provided on each listed factor. This step has been used to limit the number of rounds needed to achieve consensus.^42,44,49

The same definitions of consensus used in the first round were again used in the second round. A third round was not needed to achieve consensus on equivocal factors because clinicians made obvious comments allowing a conclusion that consensus would not be possible in a third round.

Ethics Approval

This explorative consensus-based study received ethical approval from the Institutional Review Board Committee of An-Najah National University. All clinicians provided informed consent.

RESULTS

In the first Delphi round, responses were obtained from all 50 clinicians (100%) invited. In the second Delphi round, responses were obtained from 45 clinicians (90%).

Characteristics of the Clinician Panelists

The panel included male and female clinicians. Twenty-three (46%) were internal medicine and family medicine specialists and 27 (54%) had practice experience of 10 or more years in providing health care services to patients with hypertension. The detailed sociodemographic and practice details of the clinicians who took part in the study are shown in Table 1.

Opinions on Therapeutic Inertia

The majority of the clinicians (90%) agreed that therapeutic inertia was prevalent in managing hypertension in Palestinian clinical practice and 90% also agreed on the need to exert more efforts to eliminate or reduce it. None of the clinicians (0%) reported being invited to attend a training, workshop, symposium, or lecture on therapeutic inertia. All clinicians (100%) stated that they have not heard of any guidelines or recommendations to eliminate or reduce therapeutic inertia in managing hypertension, and they also all (100%) agreed that these guidelines or recommendations were required to eliminate or reduce this phenomenon in Palestinian clinical practice.

Factors the Panelists Believed Promoted the Existence of Therapeutic Inertia in Managing Hypertension

Of the 41 potential promoters on the initial list, consensus was achieved on 37 (90.2%) promoters of the phenomenon. The details of the promoters are presented in Table 2. Of the 37 promoters on which formal consensus was achieved, 21 (56.8%) were clinician-related, 10 (27.0%) were patient-related, and 6 (16.2%) were health care system–related factors.

Factors on Which Consensus Was Not Achieved Among the Panel

Consensus was not achieved on 4 (9.8%) potential promoters of therapeutic inertia. These factors (details shown in Table 3) remained equivocal at the end of the second round.

DISCUSSION

This exploratory study sought to expose views and opinions of clinicians involved in providing health care services to patients with hypertension in Palestine with regard to therapeutic inertia. The study also sought to achieve consensus on promoters of therapeutic inertia in managing hypertension from the clinicians’ point of view. To our best knowledge, this exploratory consensus-based study is the first study among clinicians who are involved in providing health care services to patients with hypertension in Palestine. Findings of the present study could be informative to clinicians, health regulatory authorities, researchers, academicians, and all stakeholders interested in combating the phenomenon of therapeutic inertia. It has been argued that therapeutic inertia can be eliminated or reduced by appropriately designed interventions.^18,50

The clinician panelists were recruited using a judgmental sampling technique. Historically, nonprobability and nonrandomized sampling techniques have been associated with bias.⁵¹ However, the design and objectives of this study limited the use of randomized probability sampling techniques.^18,35,36 To achieve consensus on a concept using a formal consensus technique, it is a prerequisite for a panelist to have prior knowledge of the concept on which consensus is being sought. The sampling technique used in this study permitted recruiting clinicians who were actively involved in providing clinical health care services to patients in Palestine with hypertension based on the inclusion criteria. In Palestine, patients with hypertension receive health care services from general practitioners, family medicine specialists, and internal medicine specialists. Therefore, the clinicians invited and recruited were from these specialties. The size of the panel of clinicians was consistent with those used in previous explorative and consensus-based studies in which views and opinions of stakeholders were sought and consensus was developed on concepts in health care.^18,33-44

Not surprisingly, the clinicians who took part in this study were of the opinion that therapeutic inertia was prevalent in managing hypertension in Palestinian clinical practice. The study’s findings were consistent with those reported on managing hypertension in previous studies conducted elsewhere.^52-55 The clinicians wanted to see more efforts to eliminate or reduce therapeutic inertia in managing hypertension in Palestinian clinical practice. Views of the clinicians on the existence of therapeutic inertia in managing hypertension in Palestine were also consistent with those reported on managing dyslipidemia in Palestine.¹⁸ The phenomenon of therapeutic inertia was also shown to be highly prevalent in other health conditions including diabetes and dyslipidemia^16,17,56-58; in fact, it has been reported that therapeutic inertia may be part of up to 50% of patient-clinician encounters among patients with diabetes.¹⁶ Not surprisingly, none of the clinicians had ever been invited to attended any training, conference, meeting, or lecture on therapeutic inertia. Similarly, no guidelines or recommendations to eliminate or reduce therapeutic inertia were noted to exist. Findings of this study were consistent with those reported by clinicians caring for patients with dyslipidemia in Palestine.¹⁸ Our findings highlight the existence of this gap and the need to develop guidelines and recommendations and organize training.^16,31

Findings of this study complement those reported on therapeutic inertia in hypertension and other health conditions.^{16-18,31,52,53} In this study, more than half (56.8%) of the promoters were clinician-related factors, and clinicians have previously been recognized as contributors to the phenomenon of clinical inertia.^16,56-58 Lack of time, initiation, intensification, dose titration, and addressing comorbidities were cited as promoters of therapeutic inertia. Additionally, allowing patients to dominate the encounter, blaming the patient, adopting reactive strategies, lacking support of active care, overrating the quality of health care services provided, and lacking adherence to guidelines promoted therapeutic inertia. Understanding clinician-related factors might help decision makers in health care authorities and professional groups support clinicians in providing optimal health care services to patients with hypertension.⁵² The clinicians were of the opinion that denial, underestimating the risks of hypertension, resistance to lifestyle modifications, lack of health literacy, lack of financial resources, polypharmacy, fear of adverse effects, poor communication, and lack of trust were patient-related factors that promoted therapeutic inertia in managing hypertension. Consensus was also achieved on promoters related to the health care system, including the lack of each of the following: current guidelines, decision support system, active outreach system, disease registry for hypertension, visit planning system, and team approach in managing patients with hypertension. Our findings were consistent with those reported in previous studies.^{18,19,31,59,60}

Limitations

This exploratory consensus-based study has a number of limitations. First, all participants who took part were clinicians who were general practitioners, family medicine specialists, or internal medicine specialists. Although this was done intentionally, inclusion of other health care professionals such as cardiologists, endocrinologists, pharmacists, nurses, and dieticians could have allowed the collection of their views on provision of health care services for patients with hypertension.⁶¹ Second, the panel size was relatively small (although the high response rate obtained could be considered a strength). Third, patients were not included in the panel. Inclusion of patients would have provided further insights into the phenomenon from their perspectives. Fourth, decision makers from health authorities were not included. Finally, this study was qualitative in nature. Qualitative studies are limited by their approach compared with randomized controlled trials. A “gold standard” in identifying promoters of therapeutic inertia in managing hypertension is not existent. In its absence and in the absence of empirical evidence, formal consensus methods like the Delphi technique might provide alternative means to address the phenomenon of therapeutic inertia.

CONCLUSIONS

The study explored views and opinions of clinicians involved in providing health care services to patients with hypertension in Palestine that are relevant to therapeutic inertia in hypertension. From the point of view of the clinicians, the promoters of therapeutic inertia in hypertension were clinician-related, patient-related, and health care system–related factors. Findings of this study could inform policy and decision makers to devise strategies to eliminate or reduce therapeutic inertia in managing hypertension in Palestinian clinical practice. Future studies are needed to determine if such strategies can improve outcomes of patients with hypertension.

Acknowledgments

Soraida Khalaily, MD, and Doaa Abu Saleh, MD, contributed equally to the manuscript.

The authors would like to thank An-Najah National Hospital and An-Najah National University for permitting and facilitating this study.

Author Affiliations: Department of Physiology, Pharmacology, and Toxicology (RS), and Department of Medicine (SK, DAS), Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine; An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University (RS), Nablus, Palestine.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RS, SK); acquisition of data (SK, DAS); analysis and interpretation of data (RS, DAS); drafting of the manuscript (RS, SK, DAS); critical revision of the manuscript for important intellectual content (RS); statistical analysis (RS); and supervision (RS).

Address Correspondence to: Ramzi Shawahna, PhD, Department of Physiology, Pharmacology, and Toxicology, Faculty of Medicine and Health Sciences, New Campus, An-Najah National University, PO Box 7, Building 19, Office 1340, Nablus, Palestine. Email: ramzi_shawahna@hotmail.com.

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