Is therapeutic inertia present in hyperglycaemia, hypertension and hypercholesterolaemia management among adults with type 2 diabetes in three health clinics in Malaysia? a retrospective cohort study

Abstract

Background Good-quality evidence has shown that early glycaemic, blood pressure and LDL-cholesterol control in people with type 2 diabetes (T2D) leads to better outcomes. In spite of that, diseases control have been inadequate globally, and therapeutic inertia could be one of the main cause. Evidence on therapeutic inertia has been lacking at primary care setting. This retrospective cohort study aimed to determine the proportions of therapeutic inertia when treatment targets of HbA1c, blood pressure and LDL-cholesterol were not achieved in adults with T2D at three public health clinics in Malaysia. Methods The index prescriptions were those that when the annual blood tests were reviewed. Prescriptions of medication were verified, compared to the preceding prescriptions and classified as 1) no change, 2) stepping up and 3) stepping down. The treatment targets were HbA1c < 7.0% (53 mmol/mol), blood pressure (BP) < 140/90 mmHg and LDL-cholesterol < 2.6 mmol/L. Therapeutic inertia was defined as no change in the medication use in the present of not reaching the treatment targets. Descriptive, univariable, multivariable logistic regression and sensitive analyses were conducted. Results A total of 552 cohorts were available for the assessment of therapeutic inertia (78.9% completion rate). The mean (SD) age and diabetes duration were 60.0 (9.9) years and 5.0 (6.0) years, respectively. High therapeutic inertia were observed in oral anti-diabetic (61–72%), anti-hypertensive (34–65%) and lipid-lowering therapies (56–77%), and lesser in insulin (34–52%). Insulin therapeutic inertia was more likely among those with shorter diabetes duration (adjusted OR 0.9, 95% CI 0.87, 0.98). Those who did not achieve treatment targets were less likely to experience therapeutic inertia: HbA1c ≥ 7.0%: adjusted OR 0.10 (0.04, 0.24); BP ≥ 140/90 mmHg: 0.28 (0.16, 0.50); LDL-cholesterol ≥ 2.6 mmol/L: 0.37 (0.22, 0.64). Conclusions Although therapeutic intensifications were more likely in the presence of non-achieved treatment targets but the proportions of therapeutic inertia were high. Possible causes of therapeutic inertia were less of the physician behaviours but might be more of patient-related non-adherence or non-availability of the oral medications. These observations require urgent identification and rectification to improve disease control, avoiding detrimental health implications and costly consequences. Trial registration Number NCT02730754, April 6, 2016.

Prevalence and factors associated with lipid-lowering medications use for primary and secondary prevention of cardiovascular diseases among Malaysians: the REDISCOVER study

“…A Malaysian study showed that while the majority of clinicians used dyslipidaemia guidelines, there were wide variation in their practice with some clinicians did not prescribe based on the guidelines [ 41 ]. Furthermore, another study reported a high proportion of therapeutic inertia for LLM (61%), which resulted in lower odds of achieving LDL-c target [ 42 ]. Various factors have been proposed to contribute to treatment inertia, including physician’s fear of side effects, as well as the availability of appropriate medications [ 42 ].…”

“…Furthermore, another study reported a high proportion of therapeutic inertia for LLM (61%), which resulted in lower odds of achieving LDL-c target [ 42 ]. Various factors have been proposed to contribute to treatment inertia, including physician’s fear of side effects, as well as the availability of appropriate medications [ 42 ]. Inappropriate prescriptions were also observed in a previous study in the United Kingdom where most patients were initiated on statins without global CVD risk assessments, and some overtreatment also occurred in the low-risk patients [ 43 ].…”

Hypertension control in Kerala, India: A prescription-based study at primary and secondary level health care institutions

“… 31 Several studies have reported on possibility of inertia for therapeutic intensification in NCDs. 32 , 33 Studies have reported on physicians' dilemma in intensification in apparently healthy individuals 4 or fears of affecting the patient's delicate life balance. 34 …”

The Chinese Metabolic Management Centers

“…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. In a meta-analysis of 36 studies of interventions by nonphysician providers such as nurses, certified diabetes educators, and pharmacists to address therapeutic inertia in glycemic management, effective HbA1c reduction was only demonstrated at levels ≥9% and demonstrating reductions far from attaining desirable levels.…”

“… 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 cholesterol‐lowering treatment in 61% of visits. 11 …”