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Invited Commentary
Cardiology
January 10, 2022

Therapeutic Inertia and Racial Differences in Blood Pressure Control—Time to Get Moving

Author Affiliations
  • 1Division of Nephrology, Department of Medicine, University of Washington, Seattle
  • 2Office of Healthcare Equity, University of Washington, Seattle
JAMA Netw Open. 2022;5(1):e2143008. doi:10.1001/jamanetworkopen.2021.43008

Hypertension is the most common chronic health condition in the United States and is one of the most important modifiable risk factors for the prevention of cardiovascular events among adults worldwide.1 The results of numerous landmark clinical trials testing many different classes of antihypertensive agents have repeatedly demonstrated that treatment of hypertension dramatically improves clinical outcomes. Despite these data, guideline-adherent achievement of target blood pressure (BP) in individuals treated for hypertension remains frustratingly low.2 Furthermore, observational studies have shown persistent racial and ethnic differences in BP control, most notably a significantly lower proportion of Black and Hispanic patients achieving BP at or below target thresholds.3 Such disparities in care are multifactorial and include population-level, clinician-level, health systems–level, and societal/historical contributing factors related to social determinants of health, race, and ethnicity. Among these many possible factors, one important contributor may be systematic differences in appropriate clinician-initiated intensification of antihypertensive therapy for patients whose BP remains above a specific target, defined as therapeutic inertia. However, there remains a paucity of published data addressing whether therapeutic inertia differs by patient race and ethnicity, which may contribute differences in BP control among Black and Hispanic patients.

Elsewhere in JAMA Network Open, Zheutlin et al4 present the results of a secondary analysis of the landmark Systolic Blood Pressure Intervention Trial (SPRINT) in which they aimed to investigate the association of self-identified race and ethnicity with therapeutic inertia, which they defined as no antihypertensive medication intensification by study clinicians at study visits when measured BP was above the target. SPRINT was a highly influential multicenter randomized clinical trial in which adults with hypertension but without diabetes aged 50 years and older with high cardiovascular disease risk were randomized to a standard systolic BP goal of less than 140 mm Hg or an intensive systolic BP goal of less than 120 mm Hg.5 In their study, the authors4 leveraged the high degree of protocol standardization inherent in a clinical trial to robustly assess the association of race and ethnicity with therapeutic inertia, while accounting for important potential confounders, such as sociodemographic characteristics, comorbid depression, and specific antihypertensive medication classes prescribed. Change in the intensity of the antihypertensive medication regimen was quantified using a modified therapeutic intensity score (mTIS) which incorporates the number of antihypertensive medications along with the relative dose of age mediation represented as a proportion of the maximum therapeutic dose. Overall, 8556 participants were included in the final analysis, which was stratified by randomized treatment assignment: 2635 (31%) non-Hispanic Black, 831 (10%) Hispanic, and 5090 (59%) non-Hispanic White participants. The main findings in the study were that after adjustment for potential confounders, therapeutic inertia was similar for Hispanic compared with non-Hispanic White participants and in fact was lower (ie, medications were more likely to be adjusted) for non-Hispanic Black compared with non-Hispanic White participants in the standard treatment arm.

The somewhat surprising results of the study by Zheutlin et al4 should not be taken to mean that racial and ethnic differences in therapeutic inertia in hypertension treatment are absent in everyday clinical practice. Care delivered in a clinical trial environment is different in a number of important ways from care delivered outside of a research study. These differences include strict patient inclusion and exclusion criteria, the requirement for detailed informed consent, frequent study visits, requirements for the use of evaluation and treatment algorithms and protocols by clinicians, and the need for long term follow-up for event adjudication. While designed to enhance internal validity, these features may simultaneously affect generalizability of trial results to clinical practice. In SPRINT, it is possible that some of these features may have affected shared decision-making between patients and clinicians regarding whether to intensify antihypertensive therapy. For example, antihypertensive medications were provided in SPRINT at no cost to study participants, which may have alleviated economic factors associated with lower medication adherence. Additionally, due to their participation in a clinical trial, SPRINT clinicians may have been less likely vary clinical decisions or recommendations among different patients regarding antihypertensive medication dosing. SPRINT provided a standardized and highly protocoled way of adjusting medications, which likely reduced disparities in management among patients and patient groups. This is a valuable lesson with broad implications for reducing racial and ethnic disparities in achievement of evidence-based treatment targets in the general population. In hypertension management, standardized protocols for medication adjustments may limit clinician practice heterogeneity to ultimately reduce differences in BP control among racial and ethnic minority populations. Such protocols, of course, must be implemented thoughtfully to incorporate individualized clinical assessment and clinician-patient shared decision-making.

A critically important finding in the study by Zheutlin et al4 is the extremely high degree of therapeutic inertia observed in all SPRINT participants, despite and across groups defined by self-identified race or ethnicity. The unadjusted prevalence of therapeutic inertia at 36 months ranged from 50% to 85% depending on assigned treatment group. As discussed by the authors, US community-based estimates of therapeutic inertia in the treatment of hypertension are even higher. Unfortunately, granular detail regarding why treatment intensification did or did not occur at each study visit in SPRINT is not available. Potential contributors could include clinician concerns about medication efficacy or medication-associated laboratory abnormalities, patient fear regarding medication pill burden and adverse effects, concerns about adherence to newly prescribed medications, and patient mistrust of medical professionals.6 Outside the clinical trial environment, additional considerations may include prescription drug and laboratory test costs, pharmacy access, and competing demands during busy clinic vists.6 Meanwhile, publication in recent years of revised clinical practice guidelines for the treatment of hypertension that have lowered target systolic blood pressures to 130 mm Hg or even 120 mm Hg has resulted in a dramatic increase the number of individuals in the United States with uncontrolled blood pressure.7 Therapeutic inertia will thus continue to represent an important public health challenge for the foreseeable future.

How can we move forward in partnership with our patients to address the challenge of therapeutic inertia? Effective treatment of hypertension represents a challenge but also an opportunity for shared decision-making between clinicians and patients to work collaboratively to ensure appropriate BP control. To accomplish this, treating clinicians need education and support to ensure knowledge of current clinical practice guidelines; knowledge of how to manage complications of intensified antihypertensive therapies, such as electrolyte abnormalities or acute kidney injury; and training on shared decision-making, including culturally sensitive collaborative care. Similarly, care systems must be reconceived to enhance greater patient activation and to support patients around knowing how and who to contact with concerns or questions about treatment-related adverse effects. Finally, further research is needed to better define the specific factors associated with therapeutic inertia to allow tailored interventions to overcome this inertia to improve care for patients with hypertension. In designing and performing such research, it is vital that investigators engage with racial and ethnic minority groups to better explore the intersection of race, ethnicity, therapeutic decision-making, trust, and shared decision-making. There is much work to be done to improve outcomes for patients with hypertension—time to get moving!

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Article Information

Published: January 10, 2022. doi:10.1001/jamanetworkopen.2021.43008

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Rivara MB et al. JAMA Network Open.

Corresponding Author: Matthew B. Rivara, MD, Division of Nephrology, Department of Medicine, University of Washington, 325 Ninth Ave, PO Box 359606, Seattle, WA 98104 (mbr@uw.edu).

Conflict of Interest Disclosures: None reported.

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