'Clinical Inertia' Common in Uncontrolled Diabetes Patients

Marlene Busko

June 24, 2018

ORLANDO — Clinical inertia, which can be defined as "failure of healthcare providers to initiate or escalate therapy when indicated," was quite common in a large study of patients with uncontrolled type 2 diabetes, delegates heard here at the American Diabetes Association (ADA) 2018 Scientific Sessions.

"The surprising or maybe not surprising [finding] is that action was observed in 90% of patients, but only 56% of these patients came into glycemic control (HbA1c < 8.0%) within 2 years, with an average time of about 9 months," Elizabeth L. Ciemins, PhD, MPH, Director of Research & Analytics at the American Medical Group Association (AMGA) in Alexandria, Virginia, reported in her talk.

Specifically, the researchers defined clinical inertia as not being prescribed a new class of diabetes mediation or having persistent uncontrolled diabetes (HbA1c > 8.0%) in their study of outpatients in a large US national database.

One of the biggest barriers to overcoming clinical inertia is cost, Ciemins told Medscape Medical News, as insulin and newer diabetes drugs such as GLP-1 receptor agonists and SGLT-2 inhibitors are very expensive.

Or perhaps clinicians are not following guidelines to the letter, such as those from the ADA, one physician from London, UK, speculated.   

"I find the term 'clinical inertia' to be value laden. It implies 'Naughty doctor, you're not doing what your teacher is telling you to do,' with the teacher in this instance being the ADA," he said, to laughter from the audience.  

What if a clinician adhered more to the American College of Physicians (ACP) guidelines, "about which there has been much discussion, and which are much more flexible about comorbidity, age, and potential quality-adjusted life-years gained by lowering HbA1c," for example, in someone with a lot of comorbidities who is 75 years old, he said.

Moreover, did the researchers adjust for differences in income, he wondered.

Ciemins replied that uncontrolled diabetes was more likely to persist in the patients who had a lower level of education or lived in poorer neighborhoods.

Many patient- and physician-level factors, she added, could be contributing to persistent uncontrolled glycemia. However, the study was not designed to determine the factors driving clinical inertia, but to merely document the problem.

"Clinicians always blame the patients and the patients always blame the clinicians" for lack of glycemic control, she noted.  

"And both of them could blame the ADA," said the UK physician, to more laughter.

Are ADA Guidelines Being Followed?

ADA guidelines recommend escalating diabetes therapy every 3 months if the patient is not at target HbA1c levels, Ciemins explained, but several previous studies have suggested that many patients may not be receiving this recommended treatment escalation.

And clinical inertia increases with diabetes duration, patient age, and polypharmacy, she noted, but on the flip-side, physicians also need to avoid over-testing which can trigger overtreatment and potential adverse events such as hypoglycemia in older adults.

The researchers identified 281,000 outpatients with type 2 diabetes who were 18 to 75 years old and seen in 22 healthcare organizations (that were members of AMGA) during 2012 to 2017.

Of these, 27,925 patients had never taken insulin, had an index HbA1c ≥ 8.0%, had a mean age of 58 years, and about 44% were women.

During the first 6 months, nearly half of these (46%) had no observable action (range 34% to 56% of patients in the different healthcare organizations), and so were deemed to be in the "clinical inertia" group.

By 1 year, this figure was 25%, and by 18 months, it was 20%.

By 2 years, 3208 patients (11%) in all were considered to have experienced "clinical inertia" (range 7% to 19% of patients in different healthcare organizations).

Those in the clinical inertia group had a lower BMI (34.5 vs 35.3 kg/m2) and diabetes severity index (1.4 vs 1.8), compared with those in whom action was taken, and they were more likely to be Asian (2.4% vs 1.6%) or African American (14.5% vs 11.0%) (all P < 0.01).

"Lack of clinical action in the 6 months following an HbA1c ≥ 8.0% suggests clinical inertia vs ADA guidelines," the researchers conclude, "and greater rates in low-income insurance and race/ethnic minority adults suggests potential populations to target to ensure adequate treatment for diabetes."

The most successful healthcare systems were "places like Geisinger and Kaiser," Ciemins noted, "who can include expensive, but effective medications on their formularies, because they are both the providers and payers of healthcare services."

To overcome this clinical inertia, she suggested, healthcare systems should identify high performing clinics or individual providers, "and then go have a conversation and figure out what they are doing differently than other clinics or providers in the same system to achieve better outcomes."

The study was supported by Novo Nordisk as a sponsor of the AMGA Together to Goal National Diabetes Campaign through the AMGA Foundation. Ciemins has no relevant financial disclosures.

American Diabetes Association 2018 Scientific Sessions. June 22, 2018; Orlando, Florida. Abstract 1-OR.

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