Scoping and Bibliometric Analysis of Promoters of Therapeutic Inertia in Hypertension

ABSTRACT

Objectives: Therapeutic/clinical inertia is thought to be responsible for up to 80% of cardiovascular events. This study was conducted as a comprehensive scoping and bibliometric analysis of peer-reviewed scholarly documents reporting on factors associated with therapeutic/clinical inertia in caring for patients with hypertension. Additionally, this study identified the factors associated with therapeutic/clinical inertia in hypertension.

Study Design: This study was a scoping and bibliometric analysis.

Methods: The databases MEDLINE/PubMed, Embase, CINAHL/EBSCO, Cochrane, and Scopus were searched from inception to September 23, 2020, using relevant keywords. Documents reporting on factors associated with therapeutic/clinical inertia in caring for patients with hypertension were selected based on inclusion criteria. Bibliometric indicators and VOSviewer were used to analyze and map citation and keyword networks.

Results: Data were collected from 71 documents. Of those, 43 (60.6%) were original articles, 54 (76.1%) were published after 2010, and 41 (57.7%) originated from the United States. Mapping cooccurrence of terms identified 112 hot topics that were grouped into 4 clusters. A total of 41 factors associated with therapeutic/clinical inertia were identified from the documents selected. Of those, 23 (56.1%) were related to the physician, 12 (29.3%) were related to the patient, and 6 (14.6%) were related to the health care system.

Conclusions: This scoping and bibliometric study provides insights into the width and depth of scholarly peer-reviewed documents on factors associated with therapeutic/clinical inertia in caring for patients with hypertension. Findings of this study could be helpful in shaping future directions of research into therapeutic/clinical inertia in hypertension.

Am J Manag Care. 2021;27(11):e386-e394. https://doi.org/10.37765/ajmc.2021.88782

Takeaway Points

Scholarly peer-reviewed articles reporting on factors associated with therapeutic inertia in caring for patients with hypertension were analyzed using scoping and bibliometric methods.

• Therapeutic inertia is thought to be responsible for up to 80% of cardiovascular events.
• Therapeutic inertia is associated with factors related to the physician, patient, and health care system.
• Decision makers should address these factors to eliminate therapeutic inertia and improve patient outcomes in hypertension.

Evidence-based standards in caring for patients with certain disease conditions are receiving more attention in modern health care delivery.¹ Evidence-based practices are often reported as guidelines intended to inform health care providers and ensure optimal care delivery.^2,3 In modern practices, clinicians are increasingly required to individualize care plans for certain patients after taking into consideration the need for initiating, modifying, intensifying, or discontinuing therapy and/or referring patients to another appropriately recommended intervention.^4-6 However, devising individualized therapeutic care plans in adherence to current evidence-based recommendations can be challenging.

Although recent advancements in evidence-based standards and the availability of current guidelines have promoted optimizing therapeutic care plans, many patients still fail to attain certain intended therapeutic goals. Many factors could contribute to this failure. However, a phenomenon known as “therapeutic inertia” has been considered as the main contributor.^7,8 Therapeutic inertia refers to a phenomenon in which a clinician fails to manage at least 1 condition due to lack of adequate intervention.⁷ In scholarly literature, the terms therapeutic inertia, clinical inertia, and physician inertia are used synonymously in contrast with therapeutic momentum.

The existence of therapeutic inertia in managing chronic diseases for which treatment algorithms and therapeutic goals are well established, such as diabetes, hypertension, hyperlipidemia, osteoporosis, arthritis, and gout, is evident in the results of epidemiological studies from various health care systems.^7,9-13 Although the burden of therapeutic inertia is still highly debatable,¹⁴ the phenomenon of therapeutic inertia is thought to be responsible for up to 80% of cardiovascular events.^15,16 Therefore, it has been argued that eliminating therapeutic inertia is a prerequisite for improving health care delivery and patient outcomes.¹⁷

Hypertension is among the most frequently managed health problems in general practice.¹⁸ According to some estimates, more than 1.38 billion individuals around the world have hypertension as defined by systolic blood pressure of 140 mm Hg or higher and/or diastolic blood pressure of 90 mm Hg or higher.¹⁹ The global prevalence rate among adults has been estimated at 31.1%.¹⁹

Unmanaged elevated blood pressure can lead to greater disease burden and mortality.²⁰ Studies have shown that attaining optimal control of elevated blood pressure was difficult in different health care systems.^1,9,21,22 Additionally, initiation and intensification of antihypertensive therapy to achieve therapeutic goals in patients with hypertension were identified as gaps in evidence-based practice.^1,9,14,23 Despite the availability of evidence-based guidelines, designing individualized care plans for patients with hypertension could be jeopardized by factors related to the physician, patient, and/or health care system.^4,5,17,24-30

In a recent systematic review and meta-analysis, Milman et al analyzed randomized controlled trials to investigate whether interventions that aimed to reduce therapeutic inertia relevant to antihypertensive pharmacotherapy improved control of blood pressure in patients with hypertension.³¹ The study results showed that reminders, ambulatory monitors, and educational interventions improved control of blood pressure. In another integrative review, Aujoulat et al addressed the factors associated with therapeutic inertia in general.³² The review sought to address factors that were generally associated with physicians’ inaction to better understand the phenomenon of therapeutic inertia. Lebeau et al conducted a qualitative systematic review using major databases.³³ The study focused on collecting and appraising definitions of therapeutic inertia in hypertension as a concept in a trial to form an operational definition.

Despite the importance of therapeutic inertia in hypertension that was articulated in many previous works, little has been published on factors associated with therapeutic inertia in caring for patients with hypertension. Additionally, bibliometric analysis of peer-reviewed scholarly documents reporting on factors associated with therapeutic inertia in caring for patients with hypertension has not previously been performed. Bibliometric analysis has emerged as an appealing statistical tool in facilitating the presentation of peer-reviewed scholarly documents published as scientific literature.³⁴ On the other hand, the scoping approach to literature has emerged as a useful tool to determine the coverage of literature on a particular topic, provide a clear indication of the volume of scholarly documents on that topic, identify the types of documents and evidence available on the topic, identify the key concepts/definitions within the scope of the topic, examine how studies are conducted on the topic, identify the factors associated with the topic, serve as a precursor to systematic reviews on that topic, and identify knowledge gaps in that field.^35,36

Therefore, this study was conducted as a comprehensive scoping and bibliometric analysis of peer-reviewed scholarly documents reporting on factors associated with therapeutic inertia in caring for patients with hypertension. In this study, the bibliometric analysis was conducted to analyze global scholarly production on factors associated with therapeutic/clinical inertia in caring for patients, determine the documents cited most often, and explore key terms used in indexing the documents; the scoping analysis aimed to identify, collect, analyze, and qualitatively summarize evidence on the factors associated with therapeutic/clinical inertia in caring for patients with hypertension.

METHODS

Source of Documents

To identify documents reporting on factors associated with therapeutic inertia in caring for patients with hypertension, a literature search and review was conducted using the databases MEDLINE/PubMed, Embase, CINAHL/EBSCO, Cochrane, and Scopus. Citations were imported from Scopus. The decision to use Scopus was informed by the fact that it is the largest database for abstracts and citations of peer-reviewed scientific literature.³⁷ Scopus indexes more documents than either PubMed or Web of Science.

Search Strategy and Identification of Documents

In this study, the Medical Subject Heading (MeSH) terms related to “hypertension” and the key terms “clinical inertia” and “therapeutic inertia” were used to search for documents through their titles/abstracts/keywords. The search was limited to titles/abstracts/keywords because searching by topics/major headings yielded a greater number of less-relevant documents. Therefore, searching by titles/abstracts/keywords was more likely to preserve search sensitivity and was less likely to yield false positives.³⁸ The key terms “clinical inertia” and “therapeutic inertia” were used because MeSH terms relevant to inertia did not exist.³¹ The MeSH and key terms were combined using Boolean operators “AND” and “OR.” Documents were searched, identified, and retrieved through a search of the databases from inception of each database until September 23, 2020. Documents identified through the search were screened manually against the inclusion and exclusion criteria before deciding whether to include them in this scoping and bibliometric analysis.

Selection of Documents

Documents identified through the search strategy were imported from the database as research information systems (RIS) and comma separated values (CSV) files. EndNote (Clarivate Analytics) was used to open the RIS files and Excel (Microsoft Inc) was used to open the CSV files.^39,40 The file attachment option was used to upload the full text of the finally selected documents into EndNote.

Inclusion and Exclusion Criteria

In this study, documents were included if they were original articles, review articles, book chapters, conference papers, editorials, or notes reporting on factors associated with therapeutic inertia in caring for patients with hypertension. The search was not restricted by the country from which the document originated, the year the document was published, type of access, and/or publication status.

Documents in languages other than English were excluded from this study. Additionally, documents were excluded if they reported on therapeutic inertia in caring for patients with other diseases, especially when hypertension was not a comorbidity.

Extraction of Data

The full text of the documents selected was reviewed using Adobe Acrobat Pro (Adobe Inc); text sections that described factors associated with therapeutic inertia in caring for patients with hypertension were highlighted.^39,40 Sticky notes and annotations were also used. A data collection form was specifically designed for this study using an Excel spreadsheet (Microsoft Inc). The data relevant to factors associated with therapeutic inertia in caring for patients with hypertension were extracted into the data collection form.

Bibliometric Analysis

In this study, the bibliometric analysis of the data retrieved from the Scopus database included the following indicators: (1) publications by year; (2) country in which the corresponding author was based; (3) journals in which the document was published, with their Source Normalized Impact per Paper (SNIP) and impact factor (IF); and (4) the 20 most-cited documents.

Data relevant to documents reporting on factors associated with therapeutic inertia in caring for patients with hypertension were obtained from the Scopus database. Informed by previous bibliometric studies, the following indicators were obtained as RIS and CSV files^34,41: citation information, bibliographical information, abstract and keywords, funding details, and other information. For each journal, CiteScore, SNIP, and Scientific Journal Ranking were obtained from Scopus. The IF of each journal was obtained from Clarivate’s 2019 Journal Citation Reports.

Visualized Analysis

To construct and view bibliometric maps of the analyzed data, VOSviewer version 1.6.14 (Centre for Science and Technology Studies), which is a freely available tool for constructing and visualizing maps and networks, was used.⁴² In this study, bibliometric maps were constructed to visualize and analyze citations and key words were used to index documents reporting on factors associated with therapeutic inertia in caring for patients with hypertension.

RESULTS

Documents Identified Through the Search

The initial literature search yielded 234 documents. After screening the retrieved documents for those with mention of factors associated with therapeutic/clinical inertia in caring for patients with hypertension, 71 documents were identified and included in the final analysis. The results of the database search and selection of documents are shown in eAppendix Figure 1 (eAppendix available at ajmc.com). Documents included in this study are shown by year of publication in Figure 1. Characteristics of the selected documents are shown in the eAppendix.

The Most-Cited Documents

Of the 71 documents included in this study, 3 (4.2%) received more than 100 citations, 5 (7.0%) received between 51 and 100 citations, 29 (40.8%) received between 11 and 50 citations, and 28 (39.4%) received between 1 and 10 citations. Six (8.5%) documents were not cited. Table 1^7,33,43-60 lists the 20 documents cited most often.

Visualization by Mapping Document Citations

Of all documents selected, 65 (91.5%) were cited at least once. To map document citations, the documents that were cited at least once were included in the analysis. eAppendix Figure 2 shows a network visualization of citations. The documents published by Phillips et al and Okonofua et al had the highest number of citation links.

Visualization by Mapping Keywords

To identify research hot topics related to therapeutic inertia in caring for patients with hypertension, cooccurrences of terms in the title/abstract of the selected documents were mapped by network visualization. Cooccurrences of 6 author keywords were grouped into 2 clusters as shown by density visualization (Figure 2). Cluster 1 included 4 author keywords: “hypertension,” “blood pressure,” “clinical inertia,” and “therapeutic inertia.” Cluster 2 included 2 author keywords: “antihypertensive agents” and “medication adherence.” Of 848 keywords, 112 cooccurred 5 or more times. When generic terms such as human, humans, article, female, male, priority journal, adult, middle aged, major clinical study, aged, review, controlled study, retrospective study, randomized controlled trial, United States, aged 80 and over, cross-sectional studies, Spain, and qualitative research were removed, cooccurrence of the remaining 91 keywords were grouped into 4 clusters. These clusters can be seen in eAppendix Figure 3 in different colors: red, green, blue, and yellow. Cluster 1 included 35 keywords related to the disease, such as “hypertension,” “antihypertensive agents,” “blood pressure,” and “risk factors.” Cluster 2 included 30 items related to the quality of care, such as “clinical inertia,” “clinical competence,” “disease management,” and “quality of health care.” Cluster 3 included 16 items related to treatment, such as “antihypertensive therapy,” “practice guidelines,” and “angiotensin converting enzyme inhibitors.” Cluster 4 included 10 items related to comorbidities, such as “diabetes” and “dyslipidemia.”

Factors Associated With Therapeutic Inertia in Caring for Patients With Hypertension

Factors associated with therapeutic inertia in caring for patients with hypertension that were identified from the selected documents are listed in Table 2. In this study, 41 factors were identified from the documents selected. Of the factors identified, 23 (56.1%) were associated with the physician, 12 (29.3%) were associated with the patient, and 6 (14.6%) were associated with the health care system.

DISCUSSION

Recently, there has been more emphasis on improving patient outcomes through adherence to consensus-based guidelines in managing certain health conditions such as hypertension.^61-63 Since Phillips et al coined the term “therapeutic/clinical inertia,” there have been many calls to eliminate this phenomenon.^64,65 This scoping and bibliometric study was conducted to examine, analyze, and summarize the published literature relevant to the factors associated with therapeutic/clinical inertia in caring for patients with hypertension. This is the first scoping and bibliometric analysis of the factors associated with therapeutic inertia in caring for patients with hypertension. The factors associated with therapeutic inertia in caring for patients with hypertension were qualitatively summarized. The current study also assessed the production of scholarly documents on a yearly basis, authors who conducted the studies, journals in which these documents were published, and the number of citations these documents received.

Findings of this study showed that factors associated with therapeutic/clinical inertia in caring for patients with hypertension were reported in original articles, review articles, notes, book chapters, conference papers, and editorials. In this study, the majority of the documents were original and review articles. It is noteworthy that the majority of the peer-reviewed scholarly documents are original and review articles.^65,66 In this study, more than half (66.2%) of the selected documents were accessible by subscription. Although open-access publications have witnessed a steady growth in recent years, a large proportion of the peer-reviewed scholarly documents are accessible only to subscribers.⁶⁷

Findings of this study showed that the selected documents were published between 2001 and 2020. This could be explained by the fact that the term therapeutic/clinical inertia was coined by Phillips et al in 2001.⁷ Our findings also showed a steady growth of documents in recent years, as reflected by the number of documents published since 2010.

In the current study, the corresponding authors of more than half (57.7%) of the documents were based in the United States. Documents also originated from other developed countries such as Canada, Spain, France, United Kingdom, Australia, Netherlands, Sweden, Italy, and Germany. However, some documents originated from developing countries such as Ghana, China, Mexico, Sri Lanka, and Brazil. Findings of this study could reflect the high production of scholarly peer-reviewed literature in developed countries compared with developing countries.⁶⁸ Factors affecting research productivity include infrastructure for research and the availability of equipment, funding, and skilled investigators.⁶⁹

In this study, fewer than 1 in 4 documents declared receiving funds. The majority of the funds were provided by health institutions and pharmaceutical/medical companies. Funding is very important for supporting and sustaining scientific research and improving scholarly productivity.^70-73 Not surprisingly, most of the selected documents in this study were published in journals focusing on hypertension.

In this study, the vast majority (91.5%) of the documents selected were cited at least once. The network visualization of citations showed that seminal documents received a larger number of citations compared with other documents. It was not surprising to observe more citations for older documents, as the likelihood of citation increases as more time elapses since a document’s publication.^74,75 The review article by Phillips et al published in Annals of Internal Medicine received 997 citations.⁷ The most-cited documents focused on therapeutic inertia as a barrier to improving health care of patients with hypertension and on factors that were associated with the phenomenon of therapeutic inertia.^7,43 The documents cited most often were published in influential journals with high IF. In general, investigators tend to cite articles published in journals with high IF.⁷⁶

Density visualization of cooccurrence of author keywords identified 6 terms. The identified terms revealed a focus on hypertension, blood pressure, clinical inertia, and therapeutic inertia. It is noteworthy that MeSH terms for clinical or therapeutic inertia do not exist.³¹ Mapping cooccurrence of all keywords in the titles/abstracts/keywords identified 112 keywords that were grouped into 4 clusters. The identified keywords indicated focus on hypertension, patients and their characteristics, treatment and risk factors, and quality of therapy. Findings of this study showed keywords related to quality of care in the documents that were published recently. These keywords are often used in indexing scholarly documents related to the factors associated with therapeutic/clinical inertia in caring for patients with hypertension. The clustered keywords were related to many factors associated with therapeutic inertia that were identified and summarized in Table 2. The keywords were clustered in relation to hypertension, management of hypertension, the phenomenon of therapeutic inertia, comorbidities, and risk factors associated with inadequate management of hypertension.

In this study, factors associated with therapeutic inertia in caring for patients with hypertension were collected and summarized qualitatively. Factors were related to the physician (the majority of factors), patient, and health care system. In many health care systems around the world, the physician is the sole decision maker. On many occasions, patients delegate the physicians who are caring for them to make critical decisions on their behalf. Therefore, it was not surprising that the majority of the factors were related to the physician. To provide optimal health care to patients with hypertension, physicians should understand the clinical pathology of hypertension; set therapeutic goals; initiate treatment; titrate and optimize doses to achieve the therapeutic goals; address comorbidities; allocate enough time to instruct, educate, and counsel patients and address their concerns; adopt a proactive care strategy; improve delivery of services; opt for intensification of therapy when needed; possess adequate knowledge and tools and receive training in supporting patients with hypertension; appropriately weigh the significance of risks of the disease and pharmacotherapy; and follow current guidelines.^{7,8,13,43,45-89}

Patients were also responsible for promoting therapeutic/clinical inertia in hypertension. Studies have shown that patient denial, underestimation of the sequalae of the disease, resistance to lifestyle modifications, low health literacy, lack of exposure to educational programs, low economic status, nonadherence to taking medications, lack of coping with adverse effects, poor communication with the physician, lack of trust in physicians, emotional states, and substance abuse contribute to therapeutic/clinical inertia.^7,8,52,90-96

The health care system may also contribute to therapeutic/clinical inertia in hypertension by the lack of the following: clinical guidelines, decision support systems, active outreach systems, disease registries, visit planning systems, and team approach to care.^51,97,98

Strengths and Limitations

The factors identified, collected, analyzed, and summarized in this scoping and bibliometric analysis provide adequate coverage of the factors associated with therapeutic/clinical inertia in caring for patients with hypertension. In this study, the documents were searched in 5 major databases including Scopus, which is the largest database of peer-reviewed scholarly documents.³⁷ This investigation is the first to combine scoping and bibliometric approaches to address the width and depth of scholarly peer-reviewed documents on factors associated with therapeutic/clinical inertia in caring for patients with hypertension. Evidence on the factors associated with therapeutic/clinical inertia in caring for patients with hypertension was synthesized qualitatively. This study identified the need to direct future studies toward addressing factors associated with therapeutic/clinical inertia in caring for patients with hypertension. Decision makers and policy makers need to address these factors in order to improve health care delivery to and care of patients with hypertension.

The results of this study should be interpreted after considering the following limitations. First, only documents published in English were included in this study. Restricting the search to documents published in English could have excluded some documents that might have contained interesting findings. Second, a scoping approach was adopted for the literature analysis in this study. Historically, systematic approaches to literature review have been promoted as more robust in producing reproducible findings compared with other methods. In this study, a systematic review approach was not used due to the nature of the study, objectives, research questions, the problem, intervention, comparison, outcome, study design, and the number of the documents to be included.^99-101 Conversely, the scoping approach was used to identify the documents reporting on therapeutic inertia in caring for patients with hypertension and to summarize evidence qualitatively.^35,36 Third, the scientific quality of the documents included was not assessed in this study. Appraisal of the scientific quality of the documents included could have added another dimension to this investigation.

CONCLUSIONS

Factors associated with therapeutic inertia in caring for patients with hypertension can be related to the physician, patient, and/or health care system. Addressing these factors could be crucial to improving care of patients with hypertension. This scoping and bibliometric study provides insights into the breadth and depth of scholarly peer-reviewed documents on factors associated with therapeutic/clinical inertia in caring for patients with hypertension. Findings of this study could be helpful in shaping future directions of research into therapeutic/clinical inertia in hypertension. Future studies are needed to address these factors and reduce the burden of therapeutic/clinical inertia in caring for patients with hypertension.

Acknowledgments

The author would like to thank An-Najah National University for making this study possible.

Author Affiliations: Department of Physiology, Pharmacology, and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine; An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University, Nablus, Palestine.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Address Correspondence to: Ramzi Shawahna, PhD, Department of Physiology, Pharmacology, and Toxicology, Faculty of Medicine & Health Sciences, New Campus, An-Najah National University, PO Box 7, Building 19, Office 1340, Nablus, Palestine. Email: ramzi_shawahna@hotmail.com.

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