Clinical inertia in cardiovascular risk management: prevalence, associated factors, and impact on outcomes of the OPM study.

BACKGROUND

Clinical inertia, defined as the failure to initiate or intensify therapy when clinically indicated, represents a major and under-addressed barrier to achieving cardiovascular risk (CVR) factor control in primary care. Despite the availability of evidence-based guidelines and effective pharmacological treatments, many patients with uncontrolled hypertension, diabetes, or dyslipidaemia do not receive appropriate treatment intensification. We aimed to evaluate the prevalence of clinical inertia, identify associated patient-level factors, and assess its impact on CVR factor outcomes in high-risk primary care patients.

METHODS

This was a pre-specified secondary analysis of the Objetivo Punto de Mira (OPM) study, a multicentre, prospective, quasi-experimental interventional study conducted in primary care settings across nine Spanish regions (2024-2025). We included 711 participants with at least one uncontrolled CVR factor at baseline (hypertension, diabetes, or dyslipidaemia). Clinical inertia was operationalised, among therapeutically adherent patients, as the absence of documented pharmacological treatment initiation, dose escalation, or appropriate combination therapy when a risk factor remained uncontrolled. We estimated prevalence with 95% confidence intervals (CIs). Multivariable logistic regression identified factors associated with clinical inertia. Linear mixed-effects models assessed changes in CVR factors from baseline to 90-day follow-up, comparing patients with and without clinical inertia. Risk analysis quantified the association between clinical inertia and persistent uncontrolled status.

RESULTS

Among patients with uncontrolled conditions at baseline, clinical inertia was observed in 49.3% (n/N = 208/422) for hypertension, 31.1% (n/N = 73/235) for diabetes, and 38.2% (n/N = 217/568) for dyslipidaemia. Overall, 54.3% of participants (n/N = 386/711) exhibited clinical inertia in at least one condition. We found no statistically significant associations between clinical inertia and age, sex, CVR category, or excess weight. Clinical inertia significantly increased the risk of remaining uncontrolled across any condition (relative risk = 1.13; 95% CI = 1.03, 1.24; absolute risk difference = 9.3%; 95% CI = 2.4, 16.2; number needed to harm ≈ 11, P = 0.007), though not for individual conditions separately. At 90-day follow-up, patients with clinical inertia showed significantly smaller reductions in total cholesterol (between-group difference in change = 19.3 mg/dL; 95% CI = 12.4, 26.3, P < 0.001) and low-density lipoprotein cholesterol (15.5 mg/dL; 95% CI = 8.9, 22.0, P < 0.001) compared with patients who received treatment intensification. We also observed a small but statistically significant difference in body mass index reduction (0.25 kg/m2; 95% CI = 0.02, 0.49, P = 0.036). Both groups showed significant within-group reductions in systolic and diastolic blood pressure (P < 0.001); however, the magnitude of change did not differ significantly between patients with and without clinical inertia (between-group interaction P > 0.05 for systolic blood pressure and diastolic blood pressure). We found no significant between-group differences for glycaemic parameters, high-density lipoprotein cholesterol, or triglycerides.

CONCLUSIONS

Clinical inertia affects more than half of high-risk primary care patients with uncontrolled CVR factors. Patient demographic and clinical characteristics examined (age, sex, CVR category, excess weight) did not predict clinical inertia in this sample, consistent with, but not proof of, provider- and system-level influences described in prior literature.