A Retrospective Analysis of Therapeutic Inertia in Type 2 Diabetes Management Across a Diverse Population of Health Care Organizations in the USA

Abstract

Introduction If their target glycated hemoglobin (HbA 1c ) is not achieved after 3 months, timely treatment intensification is recommended in people with type 2 diabetes to maintain glycemic control and minimize vascular complications. We retrospectively investigated potential therapeutic inertia in the management of type 2 diabetes in multiple health care organizations across the USA. Methods Electronic health records were analyzed from 22 American Medical Group Association (AMGA) health care organizations. Bolus insulin-naïve patients with type 2 diabetes and HbA 1c ≥ 8.0% (≥ 64 mmol/mol) at baseline were followed for 24 months to identify the frequency and average duration of therapeutic inertia (no new class of glucose-lowering medication prescribed, or not achieving their target HbA 1c [< 8.0%; < 64 mmol/mol]). Results The study cohort comprised almost 28,000 patients. Therapeutic inertia was observed in ≈ 50% of patients after 6 months, and in > 10% after 24 months. Less therapeutic inertia was observed in patients receiving one or no oral antidiabetic drugs (OADs) (36% or 28%, respectively, at 6 months), while more inertia was seen following multiple OADs or basal insulin (54% of those on baseline basal insulin at 6 months). Although an observable action was recorded for 90% of patients, many (44%) had still not achieved their target HbA 1c after 24 months. Conclusion The results corroborate the presence of therapeutic inertia in people with type 2 diabetes, suggesting that treatment intensification guidelines are not being followed. Extensive variability in the presence of therapeutic inertia was observed both across and within organizations; investigating this further and sharing best practices across providers might help improve the quality of patient care at organizational and national levels. Supplementary Information The online version contains supplementary material available at 10.1007/s13300-020-00993-w.

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“… 29 It is known, however, that therapeutic inertia may occur – which means slower intensification of treatment than results of HbA1c are recommended in clinical guidelines. 30 , 31 Moreover, the inertia may be due to the medical staff or patients. The therapeutic inertia may be an explanation of the weaker metabolic outcome in our clinical cohort treated with metformin+insulin.…”

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“…Clinician factors, patient factors, and health care system factors, many of which are interrelated, all contribute to therapeutic inertia (14,15). Clinician-related factors include ever-evolving guidelines and treatment goals, new treatment options, formulary and insurance restrictions, time constraints during patient visits, clinicianpatient communication issues, complexities in patient disease management resulting from multiple comorbid diseases, concerns about adverse events and treatment complexity, and lack of a multidisciplinary diabetes care team (16)(17)(18)(19).…”

The Chinese Metabolic Management Centers

“…9 In a dataset of 54 healthcare organizations in the US including approximately 354 000 patients with type 2 diabetes, approximately 28 000 had HbA1c ≥8%, of whom 46%, 27%, 17%, and 12% had no additional glucose-lowering treatment at 6, 12, 18, and 24 months. 10 At public health clinics treating 522 persons with type 2 diabetes in Malaysia, therapeutic inertia in increasing glucose-lowering treatment was seen in up to 64% of visits, in increasing antihypertensive treatment in 51%, and in increasing LDL cholesterollowering treatment in 61% of visits. 11 Approaches to address therapeutic inertia are limited.…”

“…Using The Health Improvement Network (THIN) database of 254 925 people in the United Kingdom with incident type 2 diabetes followed for 5.3 years, two‐thirds had dyslipidemia and two‐thirds hypertension, but initiation of lipid‐lowering treatment was delayed 11 to 13 months, and antihypertensive treatment was delayed 20 to 22 months after first being noted 9 . In a dataset of 54 healthcare organizations in the US including approximately 354 000 patients with type 2 diabetes, approximately 28 000 had HbA1c ≥8%, of whom 46%, 27%, 17%, and 12% had no additional glucose‐lowering treatment at 6, 12, 18, and 24 months 10 11 …”