Clinical inertia in the management of Type 2 diabetes metabolic risk factors

Grant, Richard W.; Cagliero, Enrico; Dubey, A. K.; Gildesgame, Catharyn; Chueh, Henry C.; Barry, Michael J.; Singer, Daniel E.; Nathan, David M.; Meigs, James B.

doi:10.1111/j.1464-5491.2004.01095.x

Cited by 140 publications

(114 citation statements)

References 24 publications

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“…Guideline recommendations on treatment thresholds are changing over time and differ slightly between countries, and there can be differences in the health care system that influence the treatment intervention rates. However, similar low rates have been observed in other recent studies (6,7,18,19).…”

Section: Treatment Statusmentioning

confidence: 45%

Influence of Elevated Cardiometabolic Risk Factor Levels on Treatment Changes in Type 2 Diabetes

Voorham

Haaijer‐Ruskamp²,

Stolk³

et al. 2008

Diabetes Care

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Undertreatment of risk factors in patients with type 2 diabetes is common. We assessed the influence of elevated levels of blood pressure, total cholesterol, and A1C on decisions of Dutch general practitioners to change drug treatment in a cohort of 3,029 patients during a 1-year period. Respectively, 58, 71, and 21% of patients remained untreated despite poor blood pressure, lipid levels, and glycemic control. Of poorly controlled but already drug-treated patients, 52% did not receive intensification for antihypertensive medication, 81% not for lipid-lowering medication, and 43% not for glucose-lowering medication. We observed a significantly lower treatment intervention rate in moderately than in poorly controlled patients for blood pressure. This was not seen for decisions on cholesterol or A1C results. The low overall action rates observed for blood pressure and especially lipid management cannot sufficiently be explained by the use of treatment thresholds higher than those indicated by guidelines. Diabetes Care 31:501-503, 2008C onsiderable progress has been achieved regarding the quality of diabetes care, but undertreatment remains a topic of concern (1-3). Low rates of starting and intensifying treatment in patients with type 2 diabetes have been observed (4 -7). Although accepting higher risk-factor levels than indicated by guidelines has been reported as a reason for not changing treatment, few studies have examined differences in treatment intervention rates for moderately and poorly controlled patients (8 -11). Results from two provider survey studies suggest that physicians treat near-goal A1C levels more aggressively than neargoal blood pressure levels (10,12). Our aim was to assess the influence of moderately and highly elevated levels of cardiometabolic risk factors on the decision to change antihypertensive, lipid-lowering, and glucose-lowering treatment in primary care.RESEARCH DESIGN AND METHODS -We conducted a cohort study including 3,029 type 2 diabetic patients managed by 62 general practitioners. Clinical measurements and prescriptions were gathered from electronic patient records at the general practitioners' offices and a regional diabetes facility (13). Of the general practitioners, 20% practiced in a rural area and 18% in a private practice, and 16% were allowed to dispense drugs at their practice.We assessed treatment status and risk-factor level at baseline (1 October 2003), using the most recent measurements in the preceding year. Thresholds for moderately and highly elevated levels, respectively, were set, following national guidelines, at Ն140 and Ն160 mmHg for systolic blood pressure, Ն85 and Ն95 mmHg for diastolic blood pressure, Ն5 and Ն7 mmol/l for total cholesterol, and Ն7 and Ն8.5% for A1C. Treatment changes were determined during a follow-up period of 1 year. Patients receiving maximal medication at baseline, as defined by national guidelines for general practitioners and the Dutch Pharmacotherapy Compendium, were excluded (14).Treatment change was defined as the start or in...

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Section: Treatment Statusmentioning

confidence: 45%

Influence of Elevated Cardiometabolic Risk Factor Levels on Treatment Changes in Type 2 Diabetes

Voorham

Haaijer‐Ruskamp²,

Stolk³

et al. 2008

Diabetes Care

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“…6,7 However, many patients experience delays in medication intensification. [8][9][10][11][12][13] Delays in treatment initiation and intensification may be partially due to patient beliefs about their chronic diseases. Prior studies have found that patients hold inaccurate beliefs about diabetes and hypertension, which negatively impact decision-making.…”

Section: Introductionmentioning

confidence: 99%

Patients’ Future Expectations for Diabetes and Hypertension Treatments: “Through the Diet… I Think This is Going to Go Away.”

Fairchild¹,

Nathan

Quinn

et al. 2016

J GEN INTERN MED

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BACKGROUND: Diabetes and hypertension are chronic conditions for which over 90 % of patients require medication regimens that must be intensified over time. However, delays in intensification are common, and may be partially due to unrealistic patient expectations. OBJECTIVE: To explore whether patient expectations regarding their diabetes and hypertension are congruent with the natural history of these conditions. DESIGN: Qualitative analysis of semi-structured interviews. PARTICIPANTS: Sixty adults from an urban academic primary care clinic taking oral medications for both diabetes (duration <10 years) and hypertension (any duration) MAIN MEASURES: (1) Expectations for their a) current diabetes and hypertension medications, b) need for additional medications, c) likelihood of cure (not requiring medications); (2) preferences for receiving information on expected duration of treatments KEY RESULTS: The average patient age was 60 years, and 65 % were women. Nearly half (48 %) of participants expected to discontinue current diabetes medications in 6 years or less, whereas only one-fifth (22 %) expected to take medications for life. For blood pressure medications, one-third (37 %) expected to stop medicines in 6 years or less, and one-third expected to take medicines for life. The vast majority did not expect that they would need additional medications in the future (oral diabetes medications: 85 %; insulin: 87 %; hypertension medications: 93 %). A majority expected that their diabetes (65 %) and hypertension (58 %) would be cured. Most participants believed that intensifying lifestyle changes would allow them to discontinue medications, avoid additional medications, or cure their diabetes and hypertension. Nearly all participants (97 %) wanted to hear information on the expected duration of their diabetes and hypertension treatments from their healthcare provider. CONCLUSIONS: Providers should educate patients on the natural history of diabetes and hypertension in order to manage patient expectations for current and future medications. Future research should assess whether education can increase the adoption of and adherence to medications, without diminishing enthusiasm for lifestyle changes.

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“…We have designated the latter problem as clinical inertia (20), which may limit control of hypertension (21) and dyslipidemia (22) as well as diabetes (23)(24)(25)(26)(27). At Grady Memorial Hospital in Atlanta, there was more clinical inertia and A1C levels were higher in the general medicine primary care clinic as compared with the diabetes specialty clinic (28).…”

mentioning

confidence: 99%

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

et al. 2005

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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...

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Clinical inertia in the management of Type 2 diabetes metabolic risk factors

Abstract: Greater initiation and intensification of pharmaceutical therapy, particularly for elevated blood pressure or cholesterol, may represent a specific opportunity to improve metabolic control in Type 2 diabetes.

Cited by 140 publications

References 24 publications

Influence of Elevated Cardiometabolic Risk Factor Levels on Treatment Changes in Type 2 Diabetes

Influence of Elevated Cardiometabolic Risk Factor Levels on Treatment Changes in Type 2 Diabetes

Patients’ Future Expectations for Diabetes and Hypertension Treatments: “Through the Diet… I Think This is Going to Go Away.”

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

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