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Clinical Decisonmaking

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Training, feedback on performance, and clinical reminders may encourage doctors to intensify therapy for patients who need it

Doctors frequently treat patients with hypertension, high cholesterol, and diabetes. Abnormal blood pressure, cholesterol, and glucose values alone generally are sufficient to warrant treatment without further diagnostic maneuvers. Limitations in managing such problems often are due to "clinical inertia"—the failure of clinicians to initiate or intensify such therapy when indicated. In cases of clinical inertia, providers recognize the problem but fail to act. For example, blood pressure control is adequate in only about 45 percent of patients treated for hypertension; only 14 to 38 percent of patients with high low-density lipoprotein cholesterol levels are treated to reach cholesterol guideline goals; and only 33 percent of patients treated for diabetes reach recommended blood-sugar levels of less than 7 percent.

Clinical inertia is due to at least three problems, notes Lawrence S. Phillips, M.D., of the Emory University of School of Medicine, in a recent commentary. First, doctors often overestimate the care they provide. For example, doctors typically overestimate the frequency of foot examinations, blood-sugar measurements, and urine protein screening they conduct for their patients with diabetes. Second, physicians use "soft" reasons to avoid intensification of therapy. They may tell themselves, for instance, that a patient who has diabetes is beginning to improve his or her blood-sugar control or will now begin to adhere to a special diet. Third, doctors may lack the education, training, or practice organization needed to achieve therapeutic goals.

Doctors may not have been taught and may not appreciate the extent to which escalation of dosage and polypharmacy are needed for disease management, according to Dr. Phillips and his colleagues. Also, clinical experiences and training focused on "treating to target"—intensifying therapy to meet standard-of-care goals—are uncommon in most medical school and residency programs. Medical education should be modified to prepare primary care physicians to improve management of patients with problems such as hypertension, elevated cholesterol, and diabetes. Altering practice structure to include feedback on performance and/or clinical reminders will be important as well, conclude the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS09722).

See "Clinical inertia," by Dr. Phillips, William T. Branch Jr., M.D., Curtis B. Cook, M.D., and others, in the November 2001 Annals of Internal Medicine 135, pp. 825-834.

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