clinical inertia and blood pressure goal attainment

R e v i e w P a p e r

Clinical Inertia and Blood Pressure GoalAttainment

Jan Basile, MD

Optimal blood pressure (BP) control is still notbeing achieved for the majority of patients withhypertension. Although the topic of patientadherence to health care practitioner recommen-dations is less than desirable and medication non-compliance adds to the cost of health care,another issue that affects the ability to attainoptimal BP control is therapeutic, or clinical,inertia, which is the failure of health care provid-ers to initiate or intensify therapy when indi-cated. This paper will discuss therapeutic inertiaand other issues that prevent BP goal attainment.J Clin Hypertens (Greenwich). 2009;11:S5–S12.ª2009 Wiley Periodicals, Inc.

The goals for blood pressure (BP) reductionare ingrained in the belief that lower is bet-

ter. Data from the Blood Pressure LoweringTreatment Trialists’ Collaboration1 provides clearevidence that lowering BP significantly reducescardiovascular (CV) events. As defined by theSeventh Report of the Joint National Committeeon Prevention, Detection, Evaluation, and Treat-ment of High Blood Pressure (JNC 7),2 the chal-lenge to clinicians is to achieve a target BP of<140 ⁄ 90 mm Hg in the general population.According to the American College of Cardiol-

ogy ⁄ American Heart Association (ACC ⁄ AHA)recommendations, the goal in high-risk patients isa more aggressive target BP of <130 ⁄ 80 mm Hg.Included in this group are patients with ischemicheart disease, including patients with stableangina, and unstable angina ⁄ non–ST-segmentmyocardial infarction (NSTEMI) and STEMI, aswell as those with a Framingham risk score>10%. Patients with left ventricular dysfunctionwith an ejection fraction <40% have an evenlower target BP of 120 ⁄ 80 mm Hg.3

But how well are physicians doing in attainingthese goals? The answer is: they are doing better.More patients are aware that they have hyperten-sion (HTN) and more are on therapy than therewere 10 years ago. Overall, 57% of patients ontreatment are controlled to the minimum goal of<140 ⁄90 mm Hg, but, in high-risk patients, thegoal of 130 ⁄80 mm Hg is achieved only 38% ofthe time.4

CONTROL RATES: CLINICAL TRIALEXPERIENCE VS CLINICAL PRACTICEPatients in clinical trials often achieve better controlrates. Instead of a 57% control rate seen in clinicalpractice, patients in clinical trials do better, achiev-ing control rates between 65% and 80%. Theanswers as to why this occurs may help us addresssome of the barriers to more effective BP control(Table I).

There are reasons why participation in clinicaltrials provides a more favorable setting for control-ling BP than what is observed in a typical clinicalpractice. In trials, patients are usually randomizedto a fixed therapeutic antihypertensive algorithmwhereas in a practice setting, based on their age,ethnicity, comorbid conditions, and associated risk

From the Primary Care Service Line, Ralph H. JohnsonVA Medical Center, Charleston, SC and Division ofGeneral Internal Medicine ⁄ Geriatrics, MedicalUniversity of South Carolina, Charleston, SCAddress for correspondence:Jan Basile, MD, Ralph H. Johnson VA Medical Center,109 Bee Street, Charleston, SC 29401E-mail: jan.basile@med.va.gov

doi: 10.1111/j.1751-7176.2009.00210.x

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factors, physicians will often individualize therapy.In essence, an algorithm eliminates some of thedecision-making and variability. A second reason isthe use of combination therapy, either starting witha fixed-dose combination agent or using 2 individ-ual drugs. In almost all HTN clinical trials, partici-pants end up on more than 1 drug, which certainlyimproves BP control. Formulary availability andcost-free medications are also important. And, afixed appointment schedule is paramount. Accord-ing to clinical trial protocols, patients have a setnumber of visits each year, which are usually morethan the number of visits that occur in clinicalpractice, and it is the responsibility of study nursesto make sure that patients fulfill that obligation.Missed appointments are not allowed.

Contrast this with a clinic setting where medicalresidents, who are so busy with other responsibili-ties, may actually be happy when a patient withHTN does not show up (they can get back to theward that much sooner to work up their admis-sions from that day). Unfortunately, the patientmay not be seen for an additional 6 months orlonger. If the patient did not have their BP con-trolled at their previous visit and now does notshow up for their current appointment, they maygo a year with uncontrolled BP. Missed appoint-ments are a missed opportunity for BP control andshould not be dismissed. When hypertensivepatients do not show up for their clinic visit, theyneed to be contacted. It needs to be stressed tothem that it is important they be seen to controltheir disease process.

Another difference between clinical trials andclinical practice relates to the computer-basedresults that are provided in clinical trials for record

keeping. This process allows for an easy referenceto check on laboratory values (eg, serum potassium,glucose, and lipid levels) as well as long-term BPcontrol. And, finally, there is the volunteer effect.Patients sign up for clinical trials. They are vestedin helping us help them and they know that whathappens to them will affect other people withHTN in the future. If this philosophy could be car-ried over to general practice it would greatlyimprove compliance and control.

Clinicians need to understand what motivatespatients to become involved and take ownershipfor treating their own disease, especially with achronic condition like HTN. In doing so, medica-tion adherence will likely increase and outcomesare more likely to improve. Motivating factorsinclude appropriate health beliefs (such as theperceived seriousness of HTN), vulnerability tocomplications, and efficacy of the chosen treat-ment. If a treatment regimen makes sense to thepatient, seems effective, and the patient believesbenefits exceed the cost, they feel they have theability to succeed. This should translate into animprovement in overall adherence to therapy andBP control.

The volunteer effect, on the other hand, canimpact the overall results of a clinical trial. Becausethese patients are more likely to be interested,engaged, and follow directions, a selection biasmay exist that could increase the chance that BPcontrol rates will be higher in clinical trials than inreal-life practice. In addition, patients in clinical tri-als often receive increased attention and surveil-lance. Subsequent results could lead practitioners todraw the wrong conclusions of the overall efficacyof the drug(s) being studied. These points suggestthat there need to be more effectiveness trials (stud-ied under conditions similar to general practice)than efficacy studies (conducted under ideal condi-tions) if comparison on BP control percentagesbetween clinical trials and routine practice are tobe made.

Clinical trials often incorporate home BP mea-surement as a means of assessing response to ther-apy. When patients have a device at home toperform self-measurement, adherence to therapyand BP control both improve. Home monitoring ofBP eliminates white coat HTN and may help evalu-ate patients for masked HTN, identifying thepatient that often has pre-HTN in the clinic butwho actually has HTN out of the office. Home BPmore strongly relates to target organ damage andhas better prognostic accuracy than office BP. Ofcourse, in clinical practice, there is the problem of

Table I. Barriers to Blood Pressure Control

Patient

Lack of understanding of the disease state (checkingblood pressure at home)

Barriers in access to care and cost of medicationsFears and concerns about side effects of medications

Payor (health care system)High cost of medication with tiers of paymentFailure to install computerized medical record

and appointment tracking systemFailure to reimburse practitioners for non–face-to-facecare

PractitionerInappropriate medical regimensPoor communication with patientsLack of computerized medical record system

Therapeutic inertia

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reimbursement. Physicians get paid for officemeasurement of BP, and convincing insurancecompanies to reward physicians for the work theydo in monitoring out-of-office BP is a hard sell;however, this reimbursement is one that must even-tually occur. Controlling BP requires a lot of energyand takes a lot of effort from the clinician, and allof the work that is required to control BP shouldbe rewarded!

Other barriers to controlling BP include the highcost of medication and issues involving health careoffice systems that must be improved. Most officesdo not currently have a computerized medicalrecord system or an appointment tracking system,which can have a favorable effect on BP control.

THERAPEUTIC INERTIAClinicians often think they provide better care totheir patients than is actually provided. In a studyfrom Veteran Administration (VA) hospitals, resi-dent physicians were asked whether their patients’BP was controlled to levels <140 ⁄90 mm Hg.Sixty-seven percent of the residents felt that theymet the goal. However, an electronic chart auditrevealed that only 42% actually met the criteria.5

So exactly what is therapeutic inertia (TI) or clini-cal inertia? It is the failure of health care providersto initiate or intensify therapy when indicated.6 Softreasoning often leads to avoidance of therapy inten-sification. If a patients’ BP is 142 ⁄92 mm Hg, oftenno change is made in therapy since the clinicianreasons that there is no need to either up-titrate oradd another medication to further improve BP con-trol as the patient is almost at goal BP. After all,the patient will be seen again in 6 months. Thisindicates a lack of understanding of the benefits oftreating to therapeutic targets.

Burlowitz evaluated five VA medical centers inthe New England area and despite an average of�6 HTN-related visits per year among patientswith uncontrolled HTN (39% had BP >160 ⁄90mm Hg), only 25% achieved BP <140 ⁄90 mm Hg.Systolic BP fell 6.3 mm Hg in patients receiving themost intensive treatment, while BP increased overtime among those receiving the least intensive regi-men. The authors concluded that most cliniciansgenerally do not take an aggressive enoughapproach in their treatment of HTN.7 In essence,they are guilty of TI.

In a questionnaire study by Oliveria, physicianswere asked, ‘‘Was the prescribed medication forHTN initiated or changed at the patient visitwhen the systolic BP was greater than 140mm Hg?’’ The results showed that 93% of

patients had systolic BP at 140 mm Hg or higher,but only 38% of the 300 respondents had eitherstarted or changed the antihypertensive medicationat the visit.8

A study from our own group surveyed 62 prac-tices in the Carolinas-Georgia American Society ofHypertension chapter that included South Carolina,North Carolina, and Georgia. TI was defined assystolic BP >140 mm Hg and ⁄or diastolic BP >90mm Hg, with no change in antihypertensive ther-apy. This occurred in almost 87% of visits and usu-ally occurred when the BP was very close to goal.When practitioners did not suffer from TI, the sys-tolic BP was reduced an additional 13 mm Hg andthe diastolic BP another 6 mm Hg, resulting in afar better BP control rate.9 So, clearly, cliniciansthat are more likely to either increase the dose of amedicine or add a medicine are more likely to gettheir patients to goal.

Guideline adherence may also be a factor in BPcontrol. Mosca reported on a questionnaire studyof 300 primary care physicians and 100 cardiolo-gists, simply asking whether they were aware of theJNC guidelines and whether they incorporated theJNC guidelines into their practice. Only 42% actu-ally used the guidelines, even though they wereaware of the guidelines.10

In a managed care setting, a large dataset analy-sis showed that when patients were close to goal,practitioners were much less likely to either increasethe dose of medication or add a medication; how-ever, when the goal was farther away, they wereless likely to suffer from TI.11 And that makessense. However, if the object is to get BP moreeffectively controlled, and that every millimeterdoes count, patients that are close to goal but notat goal still need additional therapy.

CAUSES OF TIWhat are the causes for TI? One is clinician accep-tance of elevated BP, especially if they are satisfiedwith the current BP level. Many clinicians assumethat if BP readings have been on a downward trend,a borderline BP will likely be better the next time.In fact, the probability is just as high that the BPcould be elevated or stay the same and remainuncontrolled. Another problem is that many provid-ers seem to assume that they have ‘‘hit the finishline’’ once BP is <140 ⁄90 mm Hg. On any givenday, or even during the course of the same day, BPcould be higher or lower than the value taken in theoffice, so ‘‘just barely achieving’’ a target BP goalone time may not be good enough. Continued vigi-lance of the patients’ BP is of utmost importance!

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In addition, clinicians may focus on targeting onlyone aspect of BP, usually the diastolic reading. So,achieving a diastolic BP of <90 mm Hg is not theproblem: 73% reach that goal. However, onlyabout one third of patients achieve systolic BP<140 mm Hg. Thus, an elevated systolic BP is a met-ric that is more difficult to control and the mostimportant to address. If clinicians focus just on thistop number, at least in the adult population, BPwould be controlled in the vast majority of patients.12

Another reason for TI is time constraints. Pri-mary care clinicians following hypertensive patientshave only about 15 minutes to see a patient. Duringthis time frame they have to listen to the patient’schief complaint and take care of all of the patient’shealth care screening. So it is easy to see why a mar-ginally high BP is often not addressed. It is a prob-lem of competing interests: patients have a chiefcomplaint, chronic comorbidities, and preventivecare concerns, so little time is devoted to BP control.

Then there is a lack of clinician incentive.Adhering to guidelines and achieving treatmentgoals are not adequately rewarded in the US healthcare system. Should pay-for-performance beadopted? Should clinicians be monetarily rewardedif they are able to more effectively control BP? Anongoing multicenter study in the VA is currentlylooking at this issue. In the study, one group ofpractitioners is monetarily rewarded if they are ableto get BP controlled while a second group of practi-tioners are aware that they will not be rewarded.Does this incentive contribute to one’s ability to getBP better controlled? One concern has been thatpay-for-performance programs may penalize healthcare providers treating patients with multiplechronic coexisting conditions. A recent study exam-ined 141,609 veterans with HTN and divided theminto 4 condition groups: those with HTN and con-cordant conditions (diabetes mellitus, ischemicheart disease, dyslipidemia); those with HTN anddiscordant conditions (arthritis, depression, chronicobstructive pulmonary disease); those with both;and those with neither. Contrary to expectations,patients with greater complexity had a higher likeli-hood of receiving high-quality care for HTN. Sub-jective ratings of care did not vary with thepresence or absence of comorbid conditions. Thesefindings should reassure those who care for themost medically complex patients with HTN.13

Finally, we must examine the role of the patientwhile understanding their beliefs toward the com-plexity and seriousness of their disease. In a studyby Ross and colleagues,14 patients were asked tocomplete a questionnaire that included the beliefs

about medicines and illness perception question-naires. Analysis revealed that patients who believein the necessity of medication are more likely to becompliant (P<.001). In addition, Kressin and col-leagues15 found that patient confidence in theirability to take BP medications as prescribed wasassociated with better adherence (P�.02). There-fore, patients with more chronic conditions, espe-cially serious CV disease, may be more likely totake their medication and achieve control.

OVERCOMING CLINICAL INERTIASo what are the solutions? Utilizing a computerizedmedical record system or a noncomputerized point-of-care decision-making support system is a start. Itshould include clinical reminders or prompts to thephysician when the patients’ BP is above goal. Thisprocess should also include preventive measures,checklists, and flow sheets.

Guideline RemindersIf BP is not at goal or if the clinician is not utilizinga drug that the health care system feels the clinicianis ‘‘compelled’’ to use as part of that ‘‘cocktail,’’ aprompt should appear on the computer to remindthe physician, ‘‘Have you thought about this?’’Examples of prompts would include a patient withdiabetes who is not taking an angiotensin-convert-ing enzyme (ACE) inhibitor or an angiotensinreceptor blocker (ARB), a patient who is post–myo-cardial infarction (MI) and is not taking an ACEinhibitor or a b-blocker, or a patient with a recentMI who is not taking a statin. All of these scenarioswould elicit a computer prompt calling for a deci-sion and an action. Simplifying treatment throughthe use of algorithms needs to be adopted, imple-mented, and followed.

Other solutions include expanding clinician sup-port by utilizing nurse case managers or BP clinicsstaffed with clinical pharmacists (PharmDs). TheVA Cardiovascular Risk Reduction Clinic utilizesPharmDs for patients that have difficult-to-controlBP. These members of the health care team seepatients intercurrently when the clinician is not ableor not scheduled to do so, communicating electron-ically back to the clinician exactly what has beendiscussed. PharmDs reinforce the BP control mes-sage and the importance of medication adherencewith the patient while reviewing the patient’s medi-cation schedule with them. For example, in theCollaborative Management of Hypertension study,a physician ⁄pharmacist team achieved an 89% BPcontrol rate within 9 months using such anapproach.16 Although poor medication adherence

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was a minor problem in this population, overcom-ing TI was the likely reason for the results, as thepharmacists intensified BP medications when BPgoals were not met.

Clinician Performance FeedbackClinicians do not like to be different than their col-leagues. They do not like to see they are failing tocontrol BP as well as their peers or that in theirpatients with diabetes, fewer are taking an ACEinhibitor, ARB, or statin. In this regard, a comput-erized audit system can be a motivating incentive.17

When singled out as an outlier, physicians are moti-vated to question and determine why they are dif-ferent, oftentimes resulting in corrective measures.Similarly, a systematic self-measurement of perfor-mance and timely feedback on performance helpsmotivate physicians to overcome clinical inertia.

Combination TherapyAnother way to get around TI is to use more com-bination therapy. In the Antihypertensive and

Lipid-Lowering Treatment to Prevent Heart AttackTrial (ALLHAT), 27% of patients were initiallycontrolled to a BP goal <140 ⁄90 mm Hg. Thisimproved to 67% over the 5 years of the trial andonly 26% remained on just one drug. In fact, manywere ultimately taking 3 and some taking 4 antihy-pertensive drugs. More patients need more drugs toobtain more robust goals.18

The Food and Drug Administration (FDA) hasfinally accepted and approved many antihyperten-sive drug classes to be used in fixed-dose combina-tion pills as initial therapy. Originally onlyindicated for severe HTN, the FDA has recentlyapproved fixed-dose combination therapies as initialtherapy in patients likely to need multiple drugs toachieve BP control, which applies to the vastmajority of those with HTN.

More evidence in support of fixed-dose combina-tion therapy comes from the Avoiding Cardiovascu-lar Events Through Combination Therapy inPatients Living With Systolic Hypertension(ACCOMPLISH) trial. Although BP was initially

Figure 1. Study design for the Treatment Intervention to Control Hypertension (STITCH) trial. This study usedlow-dose diuretic ⁄ angiotensin-converting enzyme inhibitor (ACEI) or a diuretic ⁄ angiotensin receptor blocker (ARB)combination as initial therapy compared with the traditional step-cared approach of initial monotherapy currentlyrecommended by the Canadian Hypertension Education Program (CHEP). CCB indicates calcium channel blocker;HTN, hypertension; BP, blood pressure. Adapted with permission from Feldman et al.21

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controlled in 37% of those entering the trial, after6 months of treatment, control rates were up to74% starting with either an ACE inhibitor ⁄ thiazidediuretic or an ACE inhibitor ⁄calcium channelblocker. Data pooled from both fixed-dose combi-nation treatment arms showed an impressive 80%control rate (goal <140 ⁄90 mm Hg) after 30months of treatment.19

And what about the polypill? Although notappropriate for routine care, results from a study of108 treatment-naive patients with HTN who wereadministered a low-dose polypill containing 4 dif-

ferent antihypertensive agents found that BP wascontrolled more effectively using a low-dose of the4 individual agents than higher-dose treatment withany of the 4 individual components.20 Since com-plex stepped-care treatment regimens recommendedin national guidelines are not being currentlyadopted in routine clinical practice, a simpler initialfixed-dose combination algorithm (SimplifiedTreatment Intervention to Control Hypertension[STITCH]) has been evaluated in Canada.21 Thistreatment algorithm, which utilizes low-dose diure-tic ⁄ACE inhibitor or a diuretic ⁄ARB combinationas initial therapy, achieved BP control more quicklyand more effectively during the 6 months of treat-ment without any more side effects when comparedwith the traditional step-cared approach of initialmonotherapy currently recommended by the Cana-dian Hypertension Education Program. (Figure 1and Figure 2) The results of the study suggest thata simplified algorithm using initial low-dose fixed-dose combination therapy is superior to one usingan initial stepped-care single agent approach. Thisstrategy should also help to reduce TI in the future.

CONCLUSIONSWhat will it take to improve BP control(Table II)?22 First, there must be communicationbetween the physician and the patient. The BP goalshould be communicated clearly to the patient,preferably written on the prescription. Physiciansshould set clear expectations with the patient,explaining that 2 or 3 medications may be neededto control their BP, as well as the many treatmentchanges that may occur over time to achieve thetarget BP goal. In addition, many patients believethat it is a ‘‘failure’’ if BP control cannot be

Figure 2. Results from Simplified Treatment Interven-tion to Control Hypertension (STITCH). Low-dosediuretic ⁄ angiotensin-converting enzyme (ACE) inhibitoror a diuretic ⁄ angiotensin receptor blocker (ARB)combination as initial therapy significantly achievedblood pressure (BP) control more quickly and moreeffectively within the first 6 months without additionalside effects when compared with the traditionalstep-cared approach of initial monotherapy currentlyrecommended by the Canadian HypertensionEducation Program (CHEP). Adapted with permissionfrom Feldman et al.21

Table II. Ways for Clinicians and Providers to Improve Blood Pressure (BP) Control

Checklist to Improve BP Control

Communicate BP goal to the patient by writing it on the patient’sprescription bottle.

Monitor adherence, having patients bring inprescription bottles to the office.

As necessary, educate and involve the patient’s spouse,

children, and other family members on the BP goalsfor the patient.

Address side effects. Tell the patient, ‘‘If there is

any reason you cannot take the medication,please call the office and I will get back to you.’’

Emphasize the importance of changes in the patient’s lifestyle. Simplify regimens using combination tablets.

Enlist patients’ involvement in their own care by having themmeasure and record their out-of-office BP values and fax themto your office.

Use regular follow-up appointments withtelephone reminders 2 days before the appointment.

Reduce cost when it is an issue.

A missed appointment is a missed opportunity.The clinician should set clear expectations with the patient;it is likely that 2 or 3 medications will be required to controltheir BP, as well as many changes in therapy along the way toachieve their targeted BP goal.

Adapted from Cushman and Basile.22

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achieved with the first medication and they need tounderstand that this is normal.

Education and involvement of the patient’s fam-ily, spouse, and children can help improve thepatient-physician relationship. The importance oflifestyle changes should be emphasized not only tothe food buyer but also to the food preparer.Enlisting the patient’s involvement in their owncare by having them measure and record theout-of-office BP values helps engage the patient.Having patients take their own BP at homeincreases the likelihood that they will take theirmedicine and get their BP under control. If thepatient does home monitoring and sends therecorded data to the physician, the physician needsto read the report and respond to it by either call-ing the patient or seeing the patient in the office.Regardless of the practice chosen, considerationshould be given to either up-titrating or adding amedication if the BP is not under control. Inaddition, simplify the treatment regimen wheneverpossible using fixed-dose combination tablets whenthis makes financial sense.

Regular follow-up appointments using telephonereminders 2 days before the appointment helpsavoid missed opportunities. And, missed appoint-ments are missed opportunities. Physicians need tobe more vigilant in communicating with patientswho don’t show up for their appointment. We can-not forget about them because it’s less work for usthat day. Less work that day will create a backlogof care that will have to be administered in thefuture. Do today’s work today!

Disclosures: Dr Basile receives grant ⁄ research support fromthe National Heart, Lung and Blood Institute, BoehringerIngelheim, and Novartis. He has served as a consultant forAstraZeneca, Merck, Novartis, and Daiichi Sankyo and onthe speakers’ bureau of Abbott, AstraZeneca, BoehringerIngelheim, Forest, Merck, Novartis, Pfizer, and DaiichiSankyo. The author acknowledges the assistance of PracticumEducational Services in preparing this article and styling thepaper for journal submission. Editorial support was providedby Ronald K. Miller, PhD, and funded by Daiichi Sankyo,Inc. The author received an honorarium from Daiichi Sankyo,Inc, for time and effort spent preparing this article.

REFERENCES

1 Neal B, MacMahon S, Chapman N, et al; Blood PressureLowering Treatment Trialists’ Collaboration. Effects ofACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designedoverviews of randomized trials. Lancet. 2000;356:1955–1964.

2 Chobanian AV, Bakris GL, Black HR, et al; National Heart,Lung, and Blood Institute Joint National Committee on Pre-vention, Detection, Evaluation, and Treatment of HighBlood Pressure; National High Blood Pressure EducationProgram Coordinating Committee. Seventh Report of the

Joint National Committee on Prevention, Detection, Evalua-tion, and Treatment of High Blood Pressure. JAMA.2003;289:2560–2572.

3 Rosendorff C, Black HR, Cannon CP, et al; American HeartAssociation Council for High Blood Pressure Research;American Heart Association Council on Clinical Cardiol-ogy; American Heart Association Council on Epidemiologyand Prevention. Treatment of hypertension in the preventionand management of ischemic heart disease. A ScientificStatement from the American Heart Association.Circulation. 2007;115:2761–2788.

4 Ong KL, Cheung BM, Man YB, et al. Prevalence, aware-ness, treatment, and control of hypertension among Uni-ted States adults 1999–2004. Hypertension. 2007;49:69–75.

5 Steinman MA, Fischer MA, Shlipak MG, et al. Clinicianawareness of adherence to hypertension guidelines. Am JMed. 2004;117:747–754.

6 Phillips LS, Branch WT, Cook CB, et al. Clinical inertia.Ann Intern Med. 2001;135:825–834.

7 Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate man-agement of blood pressure in a hypertensive population.N Engl J Med. 1998;339:1957–1963.

8 Oliveria SA, Lapuerta P, McCarthy BD, et al. Physician-related barriers to the effective management of uncontrolledhypertension. Arch Intern Med. 2002;162:413–420.

9 Okonofua EC, Simpson KN, Jesri A, et al. Therapeuticinertia is an impediment to achieving the healthy people2010 blood pressure control goals. Hypertension. 2006;47:345–351.

10 Mosca L, Linfante AH, Benjamin EJ, et al. National studyof physician awareness and adherence to cardiovasculardisease prevention guidelines. Circulation. 2005;111:499–510.

11 Andrade SE, Gurwitz JH, Field TS, et al. Hypertensionmanagement: the care gap between clinical guidelinesand clinical practice. Am J Manag Care. 2004;10:481–486.

12 Burt VL, Whelton P, Roccella EJ, et al. Trends in theprevalence, awareness, treatment, and control of hyper-tension in the adult US population: data from the healthexamination surveys, 1960 to 1991. Hypertension. 1995;26:60–69.

13 Petersen L, Woodard LD, Henderson LM, et al. Willhypertension performance measures used for pay-for-per-formance programs penalize those who care for medi-cally complex patients? Circulation. 2009;119:2978–2985.

14 Ross S, Walker A, MacLeod MJ. Patient compliance inhypertension: role of illness perceptions and treatmentbeliefs. J Hum Hypertens. 2004;18:607–613.

15 Horne R, Clatworthy J, Polmear A, et al; Anglo-Scandina-vian Cardiac Outcomes Trial. Do hypertensive patients’beliefs about their illness and treatment influence medicationadherence and quality of life? J Hum Hypertens. 2001;15(suppl 1):S65–S68.

16 Carter BL, Bergus GR, Dawson JD, et al. A cluster ran-domized trial to evaluate physician ⁄ pharmacist collabora-tion to improve blood pressure control. J Clin Hypertens(Greenwich). 2008;10:260–271.

17 Egan BM, Lackland DT, Igho-Pemu P, et al. Cardiovascu-lar risk factor control in communities-update from theASH Carolinas-Georgia chapter, the hypertension initia-tive, and the community physicians’ network. J ClinHypertens (Greenwich). 2006;8:879–886.

18 Cushman W, Ford CE, Cutler JA, et al; ALLHAT Collab-orative Research Group. Success and predictors of bloodpressure control in diverse North American settings: theantihypertensive and lipid-lowering treatment to preventheart attack trial (ALLHAT). J Clin Hypertens. 2002;4:393–404.

SUPPL. 1 VOL. 11 NO. 12 DECEMBER 2009 THE JOURNAL OF CLINICAL HYPERTENSION S11

19 Jamerson K, Bakris GL, Dahlof B, et al; ACCOMPLISHInvestigators. Exceptional early blood pressure controlrates: the ACCOMPLISH trial. Blood Press. 2007;16:80–86.

20 Mahmud A, Feely J. Low-dose quadruple antihypertensivecombination: more efficacious than individual agents-apreliminary report. Hypertension. 2007;49:272–275.

21 Feldman R, Zou GY, Vandervoort MK, et al. A simplifiedapproach to the treatment of uncomplicated hypertension:a cluster randomized, controlled trial. Hypertension.2009;53:646–653.

22 Cushman WC, Basile J. Achieving blood pressure goals:why aren’t we? J Clin Hypertens (Greenwich). 2006;8:865–872.

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