Clinical inertia in hospitals and 24-7-365 care: a limited series, part 2
Clinical Inertia - a deeper dive
“Clinical inertia is the failure of health care providers to initiate or intensify therapy when indicated.” (Phillips et al., 2001) It is important to note that there is a difference between the management of known disorders for which clear responses are appropriate and the management of asymptomatic conditions for which the abnormality is uncertain or in which patient symptoms trigger a response by a care provider (Phillips et al., 2001). Or to be more specific, clinical inertia only exists according to Reach (2015) if:
there is a guideline or protocol with a specified response to a disorder when identified,
the care provider is aware of the guideline or protocol,
the care provider can trigger the appropriate response according to the guideline or protocol,
the guideline/protocol is appropriate to the patient,
yet, the care provider does not follow through with the trigger.
Unfortunately, several studies provide evidence that indicate this lack of follow through occurs frequently (Becker et al., 1998, Berlowitz et al., 1998, Hodgkin et al., 2016, Khunti et al., 2016, Maravic et al., 2018). O'Connor et al. (2005) reported that diabetes related clinical inertia may lead to several hundred thousand adverse events, and consequently “billions of dollars of excess healthcare charges… and tens of thousands of excess deaths per year”.
Clinical inertia is an issue for healthcare professionals and systems and is related to three dominant problems: overestimation of care provided, use of “soft” reasons for not intensifying therapy and lack of education, training and organization in meeting therapeutic goals (Phillips et al., 2001). According to Reach (2015) physician related clinical inertia may exist in nearly half of medical decisions. Correct management of protocol-based responses requires in the first instance the identification of the disorder (detection) and secondly, the initiation of intensified treatment (response) until the therapeutic goals are met.
A World Health Organization’s report proposed a greater focus on adherence to interventions over improving the efficacy of therapeutics (Sabate, 2003). The rationale for this is that no therapeutic intervention can succeed if not adhered to with the intended dose, frequency and duration. If clinical inertia is the reason for therapeutics failing to be prescribed, then overcoming the clinical inertia would be a significant step in the right direction of successfully treating the patient. Delays in intensifying treatment can pose avoidable risks to patients.
Consider for a moment how many known risk factors patients are exposed to when in acute or sub-acute care facilities for periods of time. When we ask this question to groups of staff we typically reach 10 risks within minutes:
central line infections,
catheter infections,
poly-pharmacy,
pressure ulcers,
hypo-/hyper-glycemia,
VTEs/DVTs,
falls,
delirium,
functional decline,
aspiration risk, etc.
The more important question is ‘how many of these known risk states are you actively managing reliably each day for each patient?’
While authors have identified an ‘intervention bias’ in doctors, i.e. doctors feeling compelled to do something (Keijzers et al., 2018), as discussed above, there is evidence that when presented with clinical indications for intervention, inertia occurs more than desired. An intervention bias and clinical inertia are in somewhat stark contrast to what has more recently been termed ‘masterly inactivity’ (Keijzers et al., 2018).
“Masterly Inactivity” as a counterpoint to ‘Clinical Inertia’
Physicians intervention bias, particularly with respect to an over-reliance on technology and investigations can be costly (Keijzers et al., 2018). A recent IOM report (Smith et al., 2012) lists unnecessary services of $210 billion per year in excess costs. A 2015 survey of emergency physicians found that 85% believe patients receive too many diagnostic tests, e.g. blood tests, urine tests, imaging (Kanzaria et al., 2015). In the same survey, 97% admitted to ordering at least some medically unnecessary imaging. On a positive note, survey respondents rated increased patient involvement through education (70%) and shared decision making (56%) as extremely or very helpful in reducing unnecessary imaging. The primary driver for these unnecessary diagnostics were fear of missing a low-probability diagnosis and fear of litigation (Kanzaria et al., 2015).
National and international strategies such as ‘Choosing Wisely’ have sought to reduce the level of excess costs. A key component of Choosing Wisely is the focus on physician-patient engagement with discussions about the suitability of different treatments, or the probable lack of benefit gained from intervening. There is active encouragement for ‘doing nothing’, when doing nothing is the most appropriate ‘intervention’. However, Maughan et al. (2015) found that only 45% of emergency medicine chairs had ever addressed Choosing Wisely with patients. More recently, Lin et al. (2017) found that 54.5% of emergency physician respondents reported reducing unnecessary tests and procedures as a result of the Choosing Wisely campaign, with 64.5% feeling more comfortable discussing low-value interventions with patients.
Other evidence suggests that clinicians have concerns regarding the legitimacy of large scale research trial studies in guiding individual patient interventions (Phillips et al., 2001, Aujoulat et al., 2014), particularly with respect to potential poly-pharmacy complications or interactions with other therapeutic interventions. In yet other instances, inertia may actually be physician realization that patients want ‘caring’ rather than management for silent problems (Phillips et al., 2001). And, there is of course the self-limiting illness that requires little more than “time, symptomatic treatment and self-care” (Keijzers et al., 2018). However, these should not be considered ‘clinical inertia’ but appropriate treatment.
Masterly Inactivity
‘Masterly Inactivity’ can therefore be conceived as a cognitively considered treatment strategy focused on patient centered care, appropriate moderated use of testing, diagnostics and interventions when clinical data points indicate that further intervention is not required. For such situations, Keijzers et al. (2018) outlines a 6-step process for patient care:
Empathy and acknowledgement
Symptom management.
Clinical observation.
Education about likely diagnosis and its progression.
Expectation management.
Shared-decision making.
While a strategy like Choosing Wisely could prevent excess costs, there remain complex psychosocial factors potentially limiting it’s efficacy: cultural barriers, society’s intolerance of uncertainty and error, a propensity to treat, fear of litigation (Keijzers et al., 2018). Utilizing the 6-step masterly inactivity process outlined above could serve as the rationale for the treatment strategy developed with the patient and reduce some of the concerns and pressures clinicians face.
In the next post in our series, we’ll discuss how we can mitigate clinical inertia through daily routines and processes.
References
Aujoulat, I., Jacquemin, P., Rietzschel, E., Scheen, A., Tréfois, P., Wens, J., Darras, E. & Hermans, M.P., 2014. Factors associated with clinical inertia: an integrative review. Advances in Medical Education and Practice, 141-147.
Becker, D.M., Raqueño, J.V., Yook, R.M., Kral, B.G., Blumenthal, R.S., Moy, T.F., Bezirdjian, P.J. & Becker, L.C., 1998. Nurse-Mediated Cholesterol Management Compared With Enhanced Primary Care in Siblings of Individuals With Premature Coronary Disease. Archives of Internal Medicine, 158, 1533-1539.
Berlowitz, D.R., Ash, A.S., Hickey, E.C., Friedman, R.H., Glickman, M., Kader, B. & Moskowitz, M.A., 1998. Inadequate Management of Blood Pressure in a Hypertensive Population. New England Journal of Medicine, 339, 1957-1963.
Hodgkin, D., Merrick, E.L., O’Brien, P.L., McGuire, T.G., Lee, S., Deckersbach, T. & Nierenberg, A.A., 2016. Testing for clinical inertia in medication treatment of bipolar disorder. Journal of affective disorders, 205, 13-19.
Kanzaria, H.K., Hoffman, J.R., Probst, M.A., Caloyeras, J.P., Berry, S.H. & Brook, R.H., 2015. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Academic Emergency Medicine, 22, 390-398.
Keijzers, G., Cullen, L., Egerton‐Warburton, D. & Fatovich, D.M., 2018. Don't just do something, stand there! The value and art of deliberate clinical inertia. Emergency Medicine Australasia, 30, 273-278.
Khunti, K., Nikolajsen, A., Thorsted, B., Andersen, M., Davies, M.J. & Paul, S., 2016. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes, Obesity and Metabolism, 18, 401-409.
Lin, M.P., Nguyen, T., Probst, M.A., Richardson, L.D. & Schuur, J.D., 2017. Emergency physician knowledge, attitudes, and behavior regarding ACEP's choosing wisely recommendations: a survey study. Academic Emergency Medicine, 24, 668-675.
Maravic, M., Hincapie, N., Pilet, S., Flipo, R.-M. & Lioté, F., 2018. Persistent clinical inertia in gout in 2014: An observational French longitudinal patient database study. Joint Bone Spine, 85, 311-315.
Maughan, B.C., Baren, J.M., Shea, J.A. & Merchant, R.M., 2015. Choosing wisely in emergency medicine: a national survey of emergency medicine academic chairs and division chiefs. Academic Emergency Medicine, 22, 1506-1510.
O'Connor, P.J., Sperl-Hillen, J.M., Johnson, P.E., Rush, W.A. & Blitz, G., 2005. Clinical Inertia and Outpatient Medical Errors. In K. Henriksen, J.B. Battles, E.S. Marks & D.I. Lewin (eds.) Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville, MD: Agency for Healthcare Research and Quality.
Phillips, L.S., Branch, J.W.T., Cook, C.B., Doyle, J.P., El-Kebbi, I.M., Gallina, D.L., Miller, C.D., Ziemer, D.C. & Barnes, C.S., 2001. Clinical Inertia. Annals of Internal Medicine, 135, 825-834.
Reach, G., 2015. Patients' nonadherence and doctors' clinical inertia: two faces of medical irrationality. Diabetes Management, 5, 167.
Sabate, E., 2003. Adherence to long-term therapies: evidence for action. Geneva.
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