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Research Letter |

Depression and Clinical Inertia in Patients With Uncontrolled Hypertension FREE

Nathalie Moise, MD1; Karina W. Davidson, PhD1,2; William Chaplin, PhD1,3; Steven Shea, MD, MS1,4; Ian Kronish, MD, MPH1
[+] Author Affiliations
1Center for Behavioral and Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, New York
2Department of Psychiatry, Columbia University Medical Center, New York, New York
3Department of Psychology, St John’s University, Queens, New York
4Department of Epidemiology, Joseph Mailman School of Public Health, Columbia University, New York, New York
JAMA Intern Med. 2014;174(5):818-819. doi:10.1001/jamainternmed.2014.115.
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Published online

Depression is a known risk factor for poor prognosis among patients with cardiovascular disease.1 Numerous biological and behavioral mechanisms have been proposed.2 However, few studies have investigated the association between depression and “clinical inertia,” or lack of treatment intensification in individuals not at evidence-based goals for care.3 To address this gap, we assessed whether a diagnosis of depression is associated with clinical inertia in patients with uncontrolled hypertension.

From February 2011 through September 2013, we enrolled a convenience sample of 28 nontrainee primary care providers (PCPs) (27 physicians and 1 nurse practitioner) and 158 patients with uncontrolled hypertension from 2 inner-city, academic hospital–based primary care clinics. The institutional review board of Columbia University Medical Center approved the protocol. Participants provided written informed consent. Patients were eligible if they were at least 18 years old, were prescribed 1 or more blood pressure (BP) medications, and had a BP measurement of at least 140/90 mm Hg (or ≥130/80 mm Hg for patients with diabetes mellitus [DM] or with chronic kidney disease) on at least 2 consecutively scheduled visits with their PCP. Exclusion criteria were age older than 80 years and dementia. Clinical inertia was defined as a lack of medication intensification, hypertension specialist referral, or workup for identifiable hypertension despite uncontrolled BP. Depression status was based on PCP documentation in the electronic medical record.

We assessed established predictors of clinical inertia,4 including age, sex, systolic blood pressure (SBP) measured at the current visit, SBP at the prior visit, number of BP medications, number of medical problems addressed during the visit, DM status, and medication adherence (Morisky Medication Adherence Scale). All measures were either abstracted from the medical record by a physician or, in the case of medication adherence, by interviewing patients following the clinic visit. Multilevel analysis to account for clustering within PCP was used to determine whether depression diagnosis was associated with clinical inertia after adjusting for established predictors of clinical inertia. Sensitivity analyses were performed in which we (1) excluded 36 patients with clinician uncertainty regarding BP control status (ie, documentation of ≥ 1 BP measurement at home or at the current visit that was controlled),5 (2) adjusted for PCP documentation of adherence assessment, and (3) excluded patients with DM who had an SBP between 130 and 140 mm Hg. We used SAS statistical software (version 9.3; SAS Institute Inc) for all statistical analyses.

The mean (SD) age of patients was 64.5 (8.8) years; 74.1% were women, 79.1% were Hispanic, 44.9% were diagnosed as having depression, and 61.2% had DM. On average, participants had a prior visit SBP of 158.7 (15.7) mm Hg, current visit SBP of 154.6 (16.7) mm Hg, were taking 2.5 (1.1) BP medications, and had 5.3 (2.3) problems addressed during the visit. Clinical inertia was more common among depressed than nondepressed patients (70% vs 51%; P = .02). Depression diagnosis was associated with clinical inertia in both the adjusted and unadjusted multilevel analyses (relative risk [RR], 1.40; 95% CI, 1.11-1.74; P = .004; adjusted relative risk [ARR], 1.49; 95% CI, 1.06-2.10; P = .02). The relationship remained after excluding those with at least 1 documented home or clinic SBP measurement below goal (ARR, 1.74; 95% CI, 1.07-2.83; P = .03), adjusting for adherence counseling (ARR, 1.49; 95% CI, 1.10-2.04; P = .01) and excluding patients with DM with SBP 140 mm Hg or lower (ARR, 1.49; 95% CI, 0.99-2.23; P = .06).

Among patients with uncontrolled hypertension, clinical inertia was more likely in those with a diagnosis of depression. Hence, clinical inertia may be 1 mechanism by which depressed patients have worse cardiovascular outcomes. Research has shown that patients with mental illness receive less intensive medical care, such as coronary revascularization6; our study extends this literature by demonstrating differences in clinician behavior with respect to cardiovascular risk factor management in this population. Future studies should explore the underlying processes that affect clinician treatment practices when managing a patient with depression. In the meantime, PCPs should be cautious about undertreating cardiovascular risk factors among patients identified as having depression.

Corresponding Author: Nathalie Moise, MD, Division of General Medicine, Columbia University Medical Center, 622 W 168th St, PH9 Center, Room 320, New York, NY 10032 (nm2562@cumc.columbia.edu).

Published Online: March 10, 2014. doi:10.1001/jamainternmed.2014.115.

Author Contributions: Dr Moise had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Moise, Davidson, Kronish.

Acquisition of data: Moise, Shea, Kronish.

Analysis and interpretation of data: Moise, Chaplin, Shea, Kronish.

Drafting of the manuscript: Moise, Kronish.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Moise, Chaplin, Shea, Kronish.

Obtained funding: Davidson, Kronish.

Administrative, technical, and material support: Kronish.

Study supervision: Davidson, Shea, Kronish.

Conflict of Interest Disclosures: Dr Kronish received an honoraria from Integritas Communications Group for speaking at a continuing medical education conference. No other disclosures are reported.

Funding/Support: This work was supported by funds from the National Heart, Lung, and Blood Institute (K23 HL-098359), the American Heart Association (SDG 10SDG2600321), and the Health Resources and Services Administration (T32HP10260).

Role of the Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Lett  HS, Blumenthal  JA, Babyak  MA,  et al.  Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosom Med. 2004;66(3):305-315.
PubMed   |  Link to Article
Burg  MM, Edmondson  D, Shimbo  D,  et al.  The “perfect storm” and acute coronary syndrome onset: do psychosocial factors play a role? Prog Cardiovasc Dis. 2013;55(6):601-610.
PubMed   |  Link to Article
O'Connor PJ, Sperl-Hillen JAM, Johnson PE, Rush WA, Biltz G. Clinical Inertia and Outpatient Medical Errors Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; 2005. Vol 2. Concepts and Methodology.
Heisler  M, Hogan  MM, Hofer  TP, Schmittdiel  JA, Pladevall  M, Kerr  EA.  When more is not better: treatment intensification among hypertensive patients with poor medication adherence. Circulation. 2008;117(22):2884-2892.
PubMed   |  Link to Article
Kerr  EA, Zikmund-Fisher  BJ, Klamerus  ML, Subramanian  U, Hogan  MM, Hofer  TP.  The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717-727.
PubMed   |  Link to Article
Druss  BG, Bradford  DW, Rosenheck  RA, Radford  MJ, Krumholz  HM.  Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA. 2000;283(4):506-511.
PubMed   |  Link to Article

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References

Lett  HS, Blumenthal  JA, Babyak  MA,  et al.  Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosom Med. 2004;66(3):305-315.
PubMed   |  Link to Article
Burg  MM, Edmondson  D, Shimbo  D,  et al.  The “perfect storm” and acute coronary syndrome onset: do psychosocial factors play a role? Prog Cardiovasc Dis. 2013;55(6):601-610.
PubMed   |  Link to Article
O'Connor PJ, Sperl-Hillen JAM, Johnson PE, Rush WA, Biltz G. Clinical Inertia and Outpatient Medical Errors Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; 2005. Vol 2. Concepts and Methodology.
Heisler  M, Hogan  MM, Hofer  TP, Schmittdiel  JA, Pladevall  M, Kerr  EA.  When more is not better: treatment intensification among hypertensive patients with poor medication adherence. Circulation. 2008;117(22):2884-2892.
PubMed   |  Link to Article
Kerr  EA, Zikmund-Fisher  BJ, Klamerus  ML, Subramanian  U, Hogan  MM, Hofer  TP.  The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717-727.
PubMed   |  Link to Article
Druss  BG, Bradford  DW, Rosenheck  RA, Radford  MJ, Krumholz  HM.  Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA. 2000;283(4):506-511.
PubMed   |  Link to Article

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Submit a Comment
Clinical inertia and the role of continuity of care
Posted on March 19, 2014
Carol Sinnott
Department of General Practice, University College Cork
Conflict of Interest: None Declared
Patients in this study had, on average, 5.3 medical issues addressed in a consultation. Those who had depression were less likely to have their antihypertensive treatment intensified in the index consultation under study. What would be interesting is to follow these patients with time and see if, in the course of managing the competing demands of 5.3 other issues in the consultation, the physicians involved made provisions to deal with management of hypertension in an imminent consultation. Multimorbid patients such as these may be better served by a longtitudinal relationship with one primary care physician who will make appropriate adjustments over time, rather than referral to specialists or additional investigations that may to only add to a patients burden without any benefit in blood pressure control, or indeed health.
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