Clinical inertia: when the target is missed, nothing changes

A 58-year-old woman with hypertension and diabetes returns to the office for the third time this year. Her pressure is above target again, as in the two previous visits, and so is her diabetes follow-up test. The doctor comments that the numbers "still aren't good", reinforces the diet, asks her to measure her pressure at home and schedules a return in four months. Nothing changes in the treatment. At the next return, the scene repeats.

Each visit, on its own, seems reasonable. Added together, they form a pattern that the literature calls clinical inertia: the target is not reached and the treatment stays the same. This text discusses what clinical inertia is, how common it is, why it happens, when not acting is the right decision and what helps reduce the inertia that causes harm.

Key points

• Clinical inertia is not starting or not intensifying treatment when the therapeutic target is not reached.
• It is common in hypertension, diabetes, dyslipidemia, asthma and depression, and it is associated with worse outcomes.
• There is appropriate inaction: there are legitimate reasons to keep the treatment, and the person may choose not to intensify it.
• The causes involve the doctor, the patient and the system, with emphasis on short time and uncertainty.
• Doctors have stable styles of justifying inaction, which suggests that inertia can be recognized and trained.
• Reminders, audit with feedback, team support and shared decision making help reduce inertia.

Summary

• What clinical inertia is
• How common inertia is
• The cost of waiting
• Why inertia happens
• Styles of justifying inaction
• Appropriate inaction and inappropriate inertia
• On the patient and system side
• What helps reduce inertia
• Frequently asked questions
• Final checklist

What clinical inertia is

The most used definition describes clinical inertia, also called therapeutic inertia, as the failure to start or intensify treatment when therapeutic targets are not reached (Usherwood, 2024). The concept makes sense in conditions with clear targets, a well established benefit of reaching them, effective treatments available and up-to-date guidelines (Usherwood, 2024).

It is an error of omission. Unlike a wrong prescription, which leaves a trace, the lack of adjustment goes unnoticed: there is no event on the day, no one complains and the record shows a calm visit. The harm appears years later, as a heart attack, a stroke or a kidney complication, and is rarely linked to the visits in which nothing changed.

That is why inertia is hard to see from the inside. The doctor who has seen the same person for years sees a sequence of calm visits, with a person who feels well and numbers that oscillate a little above target. Someone looking from outside, with the list of values in order, sees something else: the target was never reached and no decision was made to change that. The distance between these two readings is the space in which inertia settles.

There is also a diagnostic form of the problem. A study of 6230 people with obesity seen at primary care centers called diagnostic inertia the situation in which a risk factor is uncontrolled, without a previous diagnosis, and the doctor takes no action (Martínez-St John, 2015). It appeared in 1275 of 1816 people with undiagnosed high blood pressure, in 335 of 359 with altered blood glucose and in 1796 of 3341 with altered cholesterol (Martínez-St John, 2015).

The same study found an association between diagnostic inertia and a higher estimated cardiovascular risk (Martínez-St John, 2015). That is, those who would benefit most from an action were, in part, those who received it least. The text on benefits and harms discusses how to weigh what is gained and what is lost in each decision.

How common inertia is

The numbers vary according to the disease and the way of measuring, but the direction is consistent. In hypertension, an analysis of global data cited by a recent review gathered 1201 population studies with 104 million participants and showed that fewer than a quarter of women and fewer than one in five men with hypertension had their pressure controlled (Usherwood, 2024). Inertia is pointed out as one of the main factors for this poor control (Usherwood, 2024).

A review on hypertension reinforces that inertia is common and contributes to inadequate pressure control in different populations (Josiah Willock, 2018). The authors recall that the emphasis usually falls on patient adherence, while the role of the physician who does not adjust treatment receives less attention (Josiah Willock, 2018).

In type 2 diabetes, a systematic review of 53 articles found, in most studies, a median of more than 1 year between a test above target and treatment intensification, ranging from 0.3 to more than 7.2 years (Khunti, 2018). Inertia increased as the person was already using more medicines and decreased when the values were very high (Khunti, 2018). Almost all the data came from high-income countries, with little information on low- and middle-income countries (Khunti, 2018).

Inertia is not limited to cardiovascular and metabolic diseases. In depression followed in primary care, about one third of the follow-up periods in which the person did not have a complete response ended in a recommendation to adjust (Henke, 2009). Physicians adjusted more often when symptoms were severe, and less often when depression was less severe and did not improve, especially if the treatment already met the recommended minimum (Henke, 2009).

This pattern is revealing. When the condition is severe, urgency pushes toward change. When symptoms are moderate and the person keeps functioning, the temptation is to wait a little longer, because no one is in immediate danger. The result is that an important share of people spend months with a partial response that could improve with an adjustment.

In asthma, a review describes inertia as a useful concept for understanding why so many people remain without adequate control, despite the available treatments (Fukuda, 2023). The authors divide inertia into factors linked to the professional, to the patient and to the health system (Fukuda, 2023).

The cost of waiting

The practical question is whether delaying the adjustment makes a difference. A cohort study of 105,477 people with newly diagnosed type 2 diabetes helps answer it (Paul, 2015). Among those who remained persistently above target in the 2 years after diagnosis, about one quarter never received treatment intensification (Paul, 2015).

In people above target, a 1-year delay in intensification was associated with a higher risk of heart attack, stroke, heart failure and cardiovascular events combined (Paul, 2015). It is an observational study, with the limitations of any record analysis, but the finding is consistent with what is known about the cumulative effect of raised blood glucose and pressure.

The reasoning applies to other conditions. Each visit without an adjustment seems to postpone a decision by a few months, but the sum of postponements can mean years of exposure to a risk that had treatment. Because the harm is silent and distant, it is almost never attributed to the visit in which nothing changed.

There is also a less visible effect. When the target goes a long time without being reached, both the physician and the person may come to accept the high value as their normal. The conversation stops revolving around reaching the target and starts revolving around not getting worse. This silent shift in reference is one of the hardest forms of inertia, because no one notices they have given up.

Why inertia happens

The causes are rarely a simple lack of knowledge. A recent review lists, among clinician factors, knowledge gaps, discomfort with uncertainty about the diagnosis, the target or the evidence, concern about the safety of intensification and lack of time (Usherwood, 2024). Among patient characteristics associated with inertia are male sex, older age, shorter life expectancy, multiple diseases and values close to target (Usherwood, 2024).

Time is a concrete factor. A classic study calculated how long a family physician would need to offer all the recommended preventive services to a list of 2500 patients (Yarnall, 2003). The result was 1773 hours per year, or 7.4 hours per working day, for prevention alone, not counting acute complaints and chronic disease follow-up (Yarnall, 2003).

Inside the appointment, the schedule competes. The person arrives with a new pain, a concern about a family member or a form to fill out, and the blood pressure adjustment is left for next time. The text on how to prioritize what is serious, urgent, important and can be postponed discusses how to organize appointments with many demands.

There are also cognitive mechanisms. Some recur in doctors' justifications:

• overestimating how well the current treatment is working;
• attributing high value to a passing circumstance, such as stress or "white coat";
• expecting that a change of habits will solve it, with no defined deadline;
• trusting one's own impression more than the recorded numbers;
• postponing so as not to burden the person with one more medication;
• avoiding the difficult conversation about side effects or cost.

Several of these reasons can be legitimate in a specific appointment. The problem is when they recur, appointment after appointment, with no plan for reassessment. Inertia, in this sense, is less a wrong decision than a decision that is never made.

The text on how confidence and accuracy run separately helps to understand why the feeling that "everything is under control" does not always match the numbers.

The doctor's sense of safety also weighs in. The text on how safety lasts longer than knowledge shows why the impression that the treatment is working can persist even when the numbers say otherwise.

Styles of justifying inaction

A study with 256 family physicians taking part in a clinical trial analyzed 2638 written answers to an open question: why the treatment had not been changed as the national guidelines suggested (Lebeau, 2016). The analysis produced 69 codes, with 4764 references, and allowed a typology with seven types of doctor to be built (Lebeau, 2016).

Of the doctors with enough data, 100 were classified into a single type, and 25 did not provide enough information for classification (Lebeau, 2016). The types, with the number of doctors in each, were optimists (28), negotiators (20), checkers (15), contextualizers (13), cautious (11), rounders (8) and scientists (5) (Lebeau, 2016).

The table summarizes how each style tends to justify inaction, based on the study's descriptions.

Style	Typical justification	Question that helps
Optimist	"It's getting better, let's wait."	Is there data showing real improvement, or only the impression?
Negotiator	"The patient doesn't want more medication."	Did the person receive enough information to decide?
Checker	"I need to confirm the value first."	When and how will the confirmation be done?
Contextualizer	"His life is hard right now."	Does the context change the goal or only postpone the decision?
Cautious	"I'm afraid of side effects."	Is the risk of changing greater than the risk of not changing?
Rounder	"It's almost at target."	How many appointments has the almost been repeated for?
Scientist	"I don't trust this evidence for him."	Is the doubt recorded and does it have a plan?

One finding stands out: among the 36 doctors who provided 50 or more references, the initial type held over time and across different patients (Lebeau, 2016). This suggests that each doctor has a relatively stable style of handling the decision not to change. Knowing one's own style is a first step toward noticing when it is working as a shortcut.

The authors do not present the styles as good or bad. Each has a reasonable part: confirming a value before changing, considering the person's life context and respecting the person's preference are sensible attitudes. The risk appears when the style becomes an automatic answer, applied to every person, in every appointment, without the doctor asking whether it still makes sense in that situation.

Appropriate inaction and inappropriate inertia

An appointment without adjustment can be the right decision. A qualitative systematic review gathered 89 articles on the concept of inertia in hypertension and organized 112 codes into 4 categories: terms and definitions, who is responsible, how and why it happens, and appropriateness (Lebeau, 2014). In all categories, the authors found contradictory statements, most supported by little or no empirical data (Lebeau, 2014).

The main conclusion was that the concept needs to be split into two parts: appropriate inaction and inappropriate inertia (Lebeau, 2014). Several authors recalled that what looks like inertia can be, in the concrete situation, appropriate care (Lebeau, 2014).

There are several legitimate reasons not to intensify. The doctor may be offering other appropriate actions, such as guidance on habits or interventions to improve adherence to the current treatment (Usherwood, 2024). The person may, after being informed, choose not to intensify, and the decision should be made together (Usherwood, 2024). In frail older adults, in people with a short life expectancy or on many medicines, a less strict target may be the most sensible.

In these cases, intensifying for the sake of intensifying can cause more harm than benefit: falls from low blood pressure, episodes of low blood glucose, interactions between medicines and a treatment routine the person cannot follow. The target appropriate for a middle-aged adult without other diseases may not be the appropriate target for someone with frailty and several chronic conditions. Adjusting the target, when well justified, is not inertia; it is individualized care.

The difference between appropriate inaction and inertia lies in the record and the plan. Appropriate inaction has an explicit reason, agreed with the person, and a date to reassess. Inertia is postponement with no recorded reason, repeated out of inertia itself. The text on planned reassessment shows how to turn doubt into a follow-up plan.

Inertia has a mirror in excess. Treating risk factors in those who gain little from it also causes harm, and the text on overdiagnosis in primary care and chronic diseases discusses that other side. The balance point is the explicit decision, neither automatic to intensify nor automatic to wait.

On the patient and system side

Inertia is not only the doctor's. The person may fear one more medicine, distrust the treatment, face high cost or have difficulty understanding the plan. In these cases, the lack of adjustment reflects a conversation that did not happen or did not reach an agreement. The review on asthma describes patient-related inertia as one of the three main categories, alongside professional and system inertia (Fukuda, 2023).

The system also weighs in. Lack of access to monitoring tests or to the indicated medicines can prevent intensification, even when the doctor wants to do it (Usherwood, 2024). Short consultations, staff turnover and the absence of a scheduled follow-up mean that no one feels responsible for the adjustment.

Fragmentation makes the picture worse. A person followed by several specialists may have blood pressure measured by all of them, but each assumes another will handle the adjustment. In primary care, which coordinates care, that responsibility should have an owner, and the lack of a clear person in charge is one of the reasons the target goes years without being reached.

The team can change this picture. A study of people with type 2 diabetes followed in general medicine clinics compared 294 with timely start of the indicated injectable treatment, 219 with delayed start and 3781 who did not need it (Mdala, 2024). Access to a diabetes nurse was associated with more than double the chance of timely start (OR 2.40), while the size of the support team had a weak relationship (Mdala, 2024).

The finding is consistent with the review on hypertension, which highlights programs in which pharmacists and nurses take part in adjusting treatment as a promising way to reduce inertia (Josiah Willock, 2018). The text on the conditions for task shifting to work discusses what is needed to share this work safely.

What helps reduce inertia

The interventions with the most support combine several fronts, and a recent review lists the main ones (Usherwood, 2024):

• access to guidelines and tools at the time of the consultation, preferably integrated into the medical record;
• education of clinicians, including educational visits;
• reminders in the medical record;
• audits with feedback and reflection on practice;
• shared decision making and encouragement for the patient to ask;
• outpatient or home monitoring.

Quality improvement programs and standardized intensification protocols also appear as ways to counter inertia in hypertension (Josiah Willock, 2018). In asthma, the authors propose an approach that combines multidisciplinary work, dissemination of guidelines, use of apps and a search for lower-cost prescriptions (Fukuda, 2023).

In the office, a few simple attitudes make a difference. Looking at the trend of the last values, and not only today's, helps to notice that "almost at goal" has lasted a year. Recording the reason for not changing, when that is the case, forces the decision to be made explicit. Scheduling the follow-up with a clear objective, such as "reassess blood pressure and decide whether to intensify", keeps the next visit from being swallowed by other demands.

EHR tools help when they are well used. A chart with the evolution of blood pressure or blood glucose, an alert when the value has been above target for more than one visit and a list of team members who are off target make it possible to see the pattern that the isolated visit hides. The care is to avoid too many alerts, which end up ignored.

Talking with the person about the goal also helps. When they know what the target is and why it matters, they can ask at the next visit whether they are getting there, and that question works as a reminder coming from the person most interested in the result. The text on guidelines, strength of recommendation and level of evidence helps decide when the guideline applies to the person in front of the doctor.

Finally, recognizing one's own style of justifying inaction can be useful. The optimistic doctor can ask whether there are data showing improvement; the rounder, how long the value has been "almost there"; the negotiator, whether the person really received the information to decide. The right question at the right moment is often what separates a decision from a postponement.

Going back to the woman from the beginning of the text: at the third visit with blood pressure above target, the doctor could show her the three values side by side, ask what she thinks is happening and present the options, including waiting a little longer with a concrete plan. If she chooses to wait, the decision is recorded with the reason and the reassessment date. If she chooses to adjust, the adjustment happens that day. Either way, the visit stops being one more repetition and becomes a decision.

A practical way to bring these ideas into the visit is to pause for a few seconds before ending an appointment for a chronic disease and ask: was the goal met, and if not, what is today's decision? The text on when to take a diagnostic pause shows how to fit this kind of quick check into the routine.

Frequently asked questions

What is clinical inertia?

It is not starting or not intensifying treatment when the therapeutic goal is not met (Usherwood, 2024). It is an error of omission, which often goes unnoticed because it leaves no immediate event.

Is inertia always a mistake?

It can be an appropriate decision. A review proposed separating appropriate inaction from inappropriate inertia, because what looks like inertia may be appropriate care in the specific situation (Lebeau, 2014). The difference lies in the recorded reason and the reassessment plan.

How long is it usually waited before intensifying?

In type 2 diabetes, the median was over 1 year in most studies of a systematic review (Khunti, 2018).

Does delaying the adjustment cause harm?

In a cohort of 105,477 people with type 2 diabetes, a 1-year delay in intensification was associated with a higher risk of cardiovascular events (Paul, 2015).

Why do experienced doctors also have inertia?

Because the causes include uncertainty, fear of side effects, values close to goal and lack of time (Usherwood, 2024). Each doctor tends to have a stable style of justifying inaction (Lebeau, 2016).

Can the team help?

Yes. Access to a diabetes nurse was associated with more than double the chance of timely start of the indicated treatment (Mdala, 2024).

Final checklist

• Compare today's value with the trend of the last visits.
• When the goal is not met, decide explicitly: intensify or not.
• If you do not intensify, record the reason and agree on the decision with the person.
• Set the follow-up with a clear goal and a defined deadline.
• Rely on the team to monitor values and propose adjustments.
• Recognize your own style of justifying inaction and ask yourself the question that challenges it.

References

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8. Mdala I, Nøkleby K, Berg TJ, et al. Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice. Scand J Prim Health Care. 2024. PMID 38116986. DOI 10.1080/02813432.2023.2296118.
9. Paul SK, Klein K, Thorsted BL, et al. Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes. Cardiovasc Diabetol. 2015. PMID 26249018. DOI 10.1186/s12933-015-0260-x.
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