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

Abstract

Background: Clinical inertia is common when blood pressure (BP) is high in the office. Little is known about the extent of 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 mmHg) 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 mmHg). 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, and of these, diagnostic inertia occurred in 45 of 144 (31%). Among 239 patients taking antihypertensive medication, 141 (59%) had high awake BP, and of these, therapeutic inertia occurred in 73 of 141 (52%). In multilevel models, male gender (OR 2.81, 95%CI 1.11 - 7.08), lower awake SBP (OR 0.73 per 5 mmHg 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 mmHg 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.