Author's response to reviews Title:The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review Authors:

28 Background. Therapeutic inertia has been defined as the failure of health-care provider to 29 initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major 30 cause of uncontrolled hypertension. The exploration of its causes and the interventions to 31 reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We 32 therefore systematically searched the literature for definitions and discussions on the concept 33 of therapeutic inertia in hypertension in primary care, to try and form an operational definition. 34 Methods. A systematic review of all types of publications related to clinical inertia in 35 hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and 36 databases, BDSP, CRD and NGC were searched from the start of their databases to June 37 2013. Articles were selected independently by two authors on the basis of their conceptual 38 content, without other eligibility criteria or formal quality appraisal.and Qqualitative data were 39 extracted independently by two teams of authors. Data were analyzed using a constant 40 comparative qualitative method. 41 Results. The final selection included 89 articles. 112 codes were grouped in 4 categories: 42 semantics (terms and definitions) (semantics), “who” (physician, patient or system), “how and 43 why” (mechanisms and reasons), and "appropriateness". Regarding each of these 44 categories, a number of contradictory assertions were found, most of them relying on little or 45 no empirical data. Overall, the limits of what should be considered as inertia were not clear. 46 A number of authors insisted that what was considered deleterious inertia might in fact be 47 appropriate care, depending on the situation. 48 Conclusions. Our data analysis revealed a major lack of conceptualization of therapeutic 49 inertia in hypertension and important discrepancies regarding its possible causes, 50 mechanisms and outcomes. The concept should be split in two parts: appropriate inaction 51 and inappropriate inertia. The development of consensual and operational definitions relying 52 on empirical data and the exploration of the intimate mechanisms that underlie these 53 behaviors are now needed. 54 Registration number: none. 55