Medicine has traditionally focused on relieving patient symptoms. However, in developed countries, maintaining good health increasingly involves management of such problems as hypertension, dyslipidemia, and diabetes, which often have no symptoms. Moreover, abnormal blood pressure, lipid, and glucose values are generally sufficient to warrant treatment without further diagnostic maneuvers. Limitations in managing such problems are often due to clinical inertia-failure of health care providers to initiate or intensify therapy when indicated. Clinical inertia is due to at least three problems: overestimation of care provided; use of "soft" reasons to avoid intensification of therapy; and lack of education, training, and practice organization aimed at achieving therapeutic goals. Strategies to overcome clinical inertia must focus on medical students, residents, and practicing physicians. Revised education programs should lead to assimilation of three concepts: the benefits of treating to therapeutic targets, the practical complexity of treating to target for different disorders, and the need to structure routine practice to facilitate effective management of disorders for which resolution of patient symptoms is not sufficient to guide care. Physicians will need to build into their practice a system of reminders and performance feedback to ensure necessary care.

Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

OBJECTIVE -Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS -A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both.RESULTS -Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA 1c (A1C) with feedback ϩ reminders (⌬A1C 0.6%, final A1C 7.46%) were significantly better than control (⌬A1C 0.2%, final A1C 7.84%, P Ͻ 0.02); changes were smaller with feedback only and reminders only (P ϭ NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P Ͻ 0.001).CONCLUSIONS -Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings. Diabetes Care 28:2352-2360, 2005T ype 2 diabetes is a public health pandemic with devastating impact on morbidity, mortality, and cost. In the U.S., the prevalence of diabetes increased from 4.9% of the population in 1990 to 7.9% in 2001 (1-4), and prevalence is projected to rise to 30 million Americans in 2030 (5). The lifetime risk of diabetes is currently projected at 33 and 38% for American men and women, respectively, born in 2000 (6), with accompanying decrease in life expectancy (6 -8). Diabetes increases the risk of both microvascular (9,10) and macrovascular disease (11), and diabetes is now the sixth leading cause of death in the U.S (12). Diabetes accounted for ϳ11% of total U.S. health care expenditures in 2002 ($92 billion) (13), but better metabolic control can reduce costs (14).Most diabetes management in the U.S. takes place in primary care settings, where measures of both process and outcome indicate that care is often suboptimal. Surveys in the early 1990s revealed that many Medicare beneficiaries had limited evaluation of levels of HbA 1c (A1C), cholesterol, o...

Background: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated-clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control.Methods: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations).Results: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy