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Editor's Note
May 2014

Multimorbidity, Guidelines, and Clinical Inertia

JAMA Intern Med. 2014;174(5):819. doi:10.1001/jamainternmed.2013.14406

Many guidelines and performance measures for chronic conditions, such as hypertension, seem to assume that patients come neatly packaged with only 1 problem. But patients’ conditions are often more complicated, and many patients have more than 1 condition. We know little about the impact that this multimorbidity has on care for common conditions like hypertension.

The Research Letter by Moise et al is novel because it clearly demonstrates that co-occurrence of depression has a significant impact on the treatment of hypertension. Specifically, patients who had a blood pressure higher than 140/90 mm Hg were less likely to have their hypertension medications intensified if they also had depression. Moise et al refer to this as clinical inertia. But is clinical inertia always bad? The answer is not clear.

In some cases, clinicians may have thought that their patients’ depression was more pressing than their hypertension. Especially if the blood pressure elevation was modest, over the long-term, management of the hypertension may be best optimized by first managing depression. When a patient has multiple problems, it is challenging to prioritize what needs to be done “this visit” and what is best managed over a longer time horizon. The study by Moise et al demonstrates that we need to think hard about the best management strategies for patients with multiple medical problems.