An Endocrinologist-Supported Intervention Aimed at Providers Improves Diabetes Management in a Primary Care Site

Abstract

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...

Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin

“…On the other hand, prior studies of clinical inertia have been limited to medical record or administrative data. [7][8][9][10][11][12] Our use of direct observation is particularly well suited to the study of clinical inertia and is a strength of this study. For example, none of the prior studies of clinical inertia measured length of encounter.…”

“…[4][5][6] Recently, poor glucose control has been attributed to so-called clinical inertia on the part of physicians, defi ned as "recognition of the problem, but failure to act." [7][8][9][10][11][12] Some have even proposed methods for a measure of clinical inertia as a quality of care indicator. 13 The phenomenon of clinical inertia has been diffi cult to study because of the paucity of data on the content of the patient-physician encounter.…”

Relationship Between Patient Medication Adherence and Subsequent Clinical Inertia in Type 2 Diabetes Glycemic Management

“…Lack of medication intensification has recently been identified as a critical barrier to evidence-based care (1)(2)(3)(4)(5). Initial commentators on this so-called "clinical inertia" in diabetes management focused attention to a large extent on physician shortcomings, such as overestimates of care provided and lack of knowledge of care guidelines (6 -9).…”

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes

“…[3][4][5][6][7] Furthermore, suboptimal control is often more prevalent among African Americans. 1,2,[8][9][10][11][12][13][14][15][16][17][18][19][20] Prior research has consistently found racial differences in medication adherence. [21][22][23][24] The reasons underlying such differences are poorly understood, but are often thought to stem from differences in care access, care quality, and selfmanagement behaviors.…”

“…[21][22][23][24] The reasons underlying such differences are poorly understood, but are often thought to stem from differences in care access, care quality, and selfmanagement behaviors. 18 As medication non-adherence is associated with poor cardiometabolic risk factor control among patients with diabetes, [8][9][10][11][12][13][14] it has been suggested that differences in medication adherence may be responsible for subgroup differences in risk factor control among patients with diabetes. 18 These conclusions, however, are drawn from crosssectional studies and from analyses that fail to consider treatment intensification.…”