Clinical inertia in type 2 diabetes: a retrospective analysis of pharmacist-managed diabetes care vs. usual medical care

Abstract

BackgroundEvidence suggests that patients with type 2 diabetes (T2DM) suffer from a high rate of “clinical inertia” or “recognition of the problem but failure to act.” ObjectiveThe aim of this study is to quantify the rate of clinical inertia between two models of care: Pharmacist-Managed Diabetes Clinic (PMDC) vs. Usual Medical Care (UMC).MethodsPatients in a university based medical clinic with type 2 diabetes (T2DM) were analyzed in this retrospective cohort study. Patients were exposed to either PMDC or UMC. The difference in days to intervention in response to suboptimal laboratory values and time to achieve goal hemoglobin A1c (A1c), systolic blood pressure (SBP) and low-density lipoprotein (LDL) was compared in the two models of care.ResultsA total of 113 patients were included in the analysis of this study, 54 patients were in the PMDC and 59 patients were in the UMC group. Median time (days) to intervention for A1c values >7% was 8 days and 9 days in the PMDC and UMC groups, respectively (p>0.05). In patients with baseline A1c values >8%, median time to achieving A1c<7% was 259 days vs. 403 days in the PMDC and UMC groups, respectively (p<0.05). Median time to goal SBP was 124 days in the PMDC group and 532 days in the UMC group (p<0.05). Median time to goal LDL was 412 days in the PMDC group vs. 506 days in the UMC group (p<0.05).ConclusionsRates of clinical inertia, defined as time to intervention of suboptimal clinical values, did not differ significantly between patients enrolled in a PMDC compared to patients with UMC with respect to A1c, SBP and LDL. Participation in PMDC, however, was associated with achieving goal A1c, SBP, and LDL levels sooner compared to UMC.

Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes

“…The intensification of anti-diabetes therapies also depends on individual patient’s characteristics including age, co-morbidities, the risk of hypoglycaemia, and provider and patient’s preferences [ 13 ]. However, a high proportion of people with T2DM fail to reach the recommended glycaemic targets for a considerable period of time post diagnosis of diabetes (glycaemic burden) [ 17 – 21 ]. Among those with poor glycaemic control [HbA1c ≥7% (≥53 mmol/mol)], an overwhelmingly large proportion of people do not receive intensified treatment in time.…”

“…Among those with poor glycaemic control [HbA1c ≥7% (≥53 mmol/mol)], an overwhelmingly large proportion of people do not receive intensified treatment in time. This “delay in treatment intensification”, also termed as clinical inertia , has been discussed by some studies [ 17 – 21 ]. A recent study based on 80,000 patients with T2DM from the United Kingdom primary care system reported that the average time to intensification to two oral anti-diabetes drugs (OADs) from one OAD among patients with HbA1c above 7% (53 mmol/mol) was about 3 years [ 21 ].…”

Clinical inertia in basal insulin-treated patients with type 2 diabetes – Results from a retrospective database study in Japan (JDDM 43)

“…Patients whose treatment is not intensified as recommended, and thus remain in poor glycemic control, are at a greater risk of long-term diabetes-related complications, such as retinopathy and nephropathy [ 5 , 6 ]. Several studies have demonstrated that patients with T2D frequently do not reach glycemic target and their treatment intensification is often delayed, both in terms of initiating insulin and later intensifying insulin regimens–this is known as clinical inertia [ 7 – 10 ]. Clinical inertia is a global issue that has shown little improvement in prevalence over the last decade [ 8 ].…”

Using an Advanced Practice Pharmacist in a Team-Based Care Model to Decrease Time to Hemoglobin A1c Goal Among Patients With Type 2 Diabetes, Florida, 2017–2019

“…Only half of the patients with diabetes achieve a glycated hemoglobin A 1c (HbA 1c ) of less than 7% (1), despite the availability of effective antidiabetic therapy and clinical practice guidelines that are updated annually (2). Timely achievement of an HbA 1c goal might have a beneficial effect on clinical outcomes, such as development of macrovascular and microvascular complications of type 2 diabetes (3). The aim of our study was to analyze the time to achieve an HbA 1c of less than 7% for a pharmacist-physician managed (PPM) cohort, as compared with a usual medical care (UMC) cohort of patients with type 2 diabetes.…”