***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Insufficient awareness of hypertension guidelines by physicians may be an impediment to achieving adequate blood pressure ( BP ) control rates in clinical practice . We therefore conducted an open intervention survey among primary care physicians in 1596 centres from 16 countries in four different continents to prospect ively assess what is the BP goal defined by physicians for individual patients and what are the reasons for not intensifying antihypertensive treatment when BP goals are not achieved . Enrolled patients ( N=35 302 ) were either not treated to goal ( N=22 887 ) or previously untreated ( N=12 250 ) . Baseline systolic and diastolic BP averaged 159/95±15/12 mm Hg . BP goals defined by physicians averaged 136±6 mm Hg for systolic and 86±5 mm Hg for diastolic BP . Patients ' individual risk stratification determined BP goals . At last visit BP averaged 132/81±11/8 mm Hg and values of ⩽140/90 were reached in 92 % of untreated and 80 % of previously uncontrolled treated hypertensives . The main reasons for not intensifying antihypertensive treatment when BP remained above goal were the assumption that the time after starting the new drug was too short to attain its full effect , the satisfaction with a clear improvement of BP or with a BP nearing the goal , and the acceptance of good self- measurements . In this open intervention program in primary care , a large proportion of patients achieved recommended BP goals . The belief that a clear improvement in BP is acceptable and that the full drug effect may take up to several weeks to be reached are frequent reasons for treatment inertia when goals are not achieved Abstract Background : Some studies have described a large number of hypertensive patients who are followed by a primary care physician without achieving adequate blood pressure ( BP ) control but whose treatment nevertheless is not intensified . It is not known whether physicians are aware of this clinical inertia and what factors are associated with this problem . Objective : The aim of this study was to describe the factors associated with clinical inertia in hypertensive patients . Methods : This was an observational , cross-sectional , multicentre study conducted in a network of primary care centres and hospital hypertension units in Spain . Using a consecutive sampling approach , 512 physicians selected 5077 hypertensive patients in whom they suspected poor BP control after chart review . The main variables documented were BP control and cardiovascular risk according to European Society of Hypertension guidelines , changes in treatment after visit , type of treatment , and healthcare setting . A binomial logistic regression multivariate analysis , adjusted for physician , was performed . Results : Of the selected patients , 70.9 % had poor BP control according to measurements taken in the physician ’s office , and in 1499 ( 42.1 % ) of those poorly controlled patients , treatment was not intensified ( clinical inertia ) . Factors associated with clinical inertia were as follows : being seen at a primary care centre ( p<0.001 ) , not having left ventricular hypertrophy ( p<0.001 ) or microalbuminuria ( p<0.001 ) , taking fixed-dose ( p=0.049 ) or free-dose ( p=0.001 ) combination therapy , BP measured in other setting s ( nurse ’s office , patient ’s home ) than the physician ’s office ( p=0.034 ) or the pharmacy ( p=0.019 ) , older age ( p=0.032 ) , and lower systolic ( p<0.001 ) and diastolic ( p<0.001 ) BP . Of the hypertensive patients with clinical inertia , 90.2 % ( 95 % CI 88.7 , 91.7 ) had high cardiovascular risk . Conclusions : Clinical inertia was associated with a profile that included older age , lack of co-morbid conditions and being seen at a primary care centre Background Hypertension is one of the key factors causing cardiovascular diseases . A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values . Shared decision making ( SDM ) is to enhance the active role of patients . As until now there exists little information on the effects of SDM training in antihypertensive therapy , we tested the effect of an SDM training programme for general practitioners ( GPs ) . Our hypotheses are that this SDM training ( 1 ) enhances the participation of patients and ( 2 ) leads to an enhanced decrease in blood pressure ( BP ) values , compared to patients receiving usual care without prior SDM training for GPs . Methods The study was conducted as a cluster r and omised controlled trial ( c RCT ) with GP practice s in Southwest Germany . Each GP practice included patients with treated but uncontrolled hypertension and /or with relevant comorbidity . After baseline assessment ( T0 ) GP practice s were r and omly allocated into an intervention and a control arm . GPs of the intervention group took part in the SDM training . GPs of the control group treated their patients as usual . The intervention was blinded to the patients . Primary endpoints on patient level were ( 1 ) change of patients ’ perceived participation ( SDM-Q-9 ) and ( 2 ) change of systolic BP ( 24h-mean ) . Secondary endpoints were changes of ( 1 ) diastolic BP ( 24h-mean ) , ( 2 ) patients ’ knowledge about hypertension , ( 3 ) adherence ( MARS-D ) , and ( 4 ) cardiovascular risk score ( CVR ) . Results In total 1357 patients from 36 general practice s were screened for blood pressure control by ambulatory blood pressure monitoring ( ABPM ) . Thereof 1120 patients remained in the study because of uncontrolled ( but treated ) hypertension and /or a relevant comorbidity . At T0 the intervention group involved 17 GP practice s with 552 patients and the  control group 19 GP practice s with 568 patients . The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints . Conclusion The study hypothesis that the SDM training enhanced patients ’ perceived participation and lowered their BP could not be confirmed . Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care . Trial registration German Clinical Trials Register ( DRKS ) : BACKGROUND Less than one third of the 65 million Americans with hypertension have adequate blood pressure ( BP ) control . This study examined the effectiveness of 2 interventions for improving patient BP control . METHODS This was a 2-level ( primary care provider and patient ) cluster r and omized trial with 2-year follow-up occurring among patients with hypertension enrolled from a Veterans Affairs Medical Center primary care clinic . Primary care providers ( n = 17 ) in the intervention received computer-generated decision support design ed to improve guideline concordant medical therapy at each visit ; control providers ( n = 15 ) received a reminder at each visit . Patients received usual care or a bimonthly tailored nurse-delivered behavioral telephone intervention to improve hypertension treatment . The primary outcome was proportion of patients who achieved a BP < 140/90 mm Hg ( < 130/85 for diabetic patients ) over the 24-month intervention . RESULTS Of the 816 eligible patients contacted , 190 refused and 38 were excluded . The 588 enrolled patients had a mean age of 63 years , 43 % had adequate baseline BP control , and 482 ( 82 % ) completed the 24-month follow-up . There were no significant differences in amount of change in BP control in the 3 intervention groups as compared to the hypertension reminder control group . In secondary analyses , rates of BP control for all patients receiving the patient behavioral intervention ( n = 294 ) improved from 40.1 % to 54.4 % at 24 months ( P = .03 ) ; patients in the nonbehavioral intervention group improved from 38.2 % to 43.9 % ( P = .38 ) , but there was no between-group differences at the end of the study . CONCLUSION The brief behavioral intervention showed improved outcomes over time , but there were not significant between group differences Detection , treatment and control of high blood pressure in many population s are insufficient . We reported current prevalence , awareness , treatment and control of hypertension in the Netherl and s and compared the findings with other studies . Furthermore , we related actual treatment of hypertension to estimated absolute 10-year cardiovascular risk , as according to current guidelines on this subject , initiation of blood pressure-lowering treatment depends on the level of cardiovascular risk . The Utrecht Health Project is a prospect i ve cohort study in a suburb of Utrecht . Information on medical history , life style and measurements of blood pressure , cholesterol and glucose of the first 4950 participants of the study was obtained . Cardiovascular risks were calculated using the Framingham risk function . Prevalence of hypertension was 23.3 % . Among those with hypertension , 33.7 % was aware of the condition . Of those aware , 59.4 % was treated . Of those treated , 41.9 % had blood pressure below the recommended level . In half of those aware of their hypertension , and a calculated cardiovascular risk less than 10 % , treatment of hypertension was started unnecessary . Of those aware of their hypertension with a calculated cardiovascular 10 years risk exceeding the treatment threshold of 20 % , treatment was absent in 33.6 % . Awareness and control of hypertension are still inadequate in the Netherl and s and comparable with other European countries . Management of hypertension is too often not risk-based despite recommendations in guidelines on prevention of cardiovascular diseases available since 2000 Factors contributing to low adherence to clinical guidelines by clinicians are not well understood . The user interface of ATHENA-HTN , a guideline -based decision support system ( DSS ) for hypertension , presents a novel opportunity to collect clinician feedback on recommendations displayed at the point of care . We analyzed feedback from 46 clinicians who received ATHENA advisories as part of a 15-month r and omized trial to identify potential reasons clinicians may not intensify hypertension therapy when it is recommended . Among the 368 visits for which feedback was provided , clinicians commonly reported they did not follow recommendations because : recorded blood pressure was not representative of the patient 's typical blood pressure ; hypertension was not a clinical priority for the visit ; or patients were nonadherent to medications . For many visits , current quality -assurance algorithms may incorrectly identify clinical ly appropriate decisions as guideline nonadherent due to incomplete capture of relevant information . We present recommendations for how automated DSSs may help identify " apparent " barriers and better target decision support BACKGROUND A cross-sectional content analysis nested within a r and omized , controlled trial was conducted to collect information on provider responses to computer alerts regarding guideline recommendations for patients with suboptimal hypertension care . METHODS Participants were providers who cared for 1,017 patients with uncontrolled hypertension on a single antihypertensive agent within Veterans Affairs primary care clinics . All reasons for action or inaction were sorted into a framework to explain the variation in guideline adaptation . RESULTS The 184 negative provider responses to computer alerts contained explanations for not changing patient treatment ; 76 responses to the alerts were positive , that is , the provider was going to make a change in antihypertensive regimen . The negative responses were categorized as : inertia of practice ( 66 % ) , lack of agreement with specific guidelines ( 5 % ) , patient-based factors ( 17 % ) , environmental factors ( 10 % ) , and lack of knowledge ( 2 % ) . Most of the 135 providers classified as inertia of practice indicated , " Continue current medications and I will discuss at the next visit . " The median number of days until the next visit was 45 days ( interquartile range , 29 to 78 days ) . DISCUSSION Clinical inertia was the primary reason for failing to engage in otherwise indicated treatment change in a subgroup of patients . A framework was provided as a taxonomy for classification of provider barriers This study evaluated physician adherence to the Seventh Report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of  High Blood Pressure ( JNC 7 ) hypertension guidelines in 6 community-based clinics . Explicit review of retrospective medical record data for patients with uncontrolled hypertension measured guideline adherence using 22 criteria . Mean overall guideline adherence was 53.5 % and did not improve significantly over time . R and om-effects models demonstrated significant associations between guideline adherence and various demographic and medical predictors , including age , minority status , comorbid conditions , and number of medications . A subsequent implicit review evaluated the degree to which nonadherence was justifiable and identified factors that might have affected adherence . Nonadherence was rated as justifiable for only 6.6 % of the failed explicit criteria . In general , adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration Context Why do clinicians fail to intensify antihypertensive therapy when a patient 's blood pressure is elevated ? Contribution This study involved 1169 diabetic patients seen by 92 primary care providers at 9 Veterans Affairs facilities . All had elevated triage blood pressures , but only half received antihypertensive treatment intensification by providers . Patient reports of home blood pressures or repeated blood pressures by providers within normal limits and discussion of medication issues decreased the likelihood of antihypertensive intensification at clinic visits . Implication Uncertainty about true blood pressure values may underlie many reasons why physicians do not intensify antihypertensive therapy . The Editors Despite some recent improvements in blood pressure control , the number of patients with inadequate control remains high and contributes to excess morbidity and mortality , especially among patients at high risk from complications of hypertension ( 
    Output:
    
A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care , depending on the situation .