Posted Jun 19 , 2018 04:14 AM

Clinical Inertia in Type 2 Diabetes Management: Evidence from a Large, Real-World Data Set

Pantalone KM, et al. Diabetes Care 2018_Online April 20th

What were the findings (excerpted from the Abstract)?

Despite clinical practice guidelines that recommend frequent monitoring of A1C (every 3 months) and aggressive escalation of antihyperglycemic therapies until glycemic targets are reached, the intensification of therapy in patients with type 2 diabetes (T2D) not at target is often inappropriately delayed. The failure of clinicians to intensify therapy when clinically indicated has been termed “clinical inertia.” The authors previously reported a rather high rate of clinical inertia in patients not at target on metformin monotherapy. Treatment was not intensified early (within 6 months of not reaching glycemic target on metformin monotherapy) in 38%, 31%, and 28% of patients when glycemic targets were defined as an A1C of ≤7%, ≤7.5%, and ≤8%, respectively. Using the electronic health record system at Cleveland Clinic (2005–2016), the authors identified a cohort of 7,389 patients with T2D who had an A1C value ≥7% (“index A1C”) despite having been on a stable regimen of two oral antihyperglycemic drugs (OADs) for at least 6 months prior to the index A1C. For the subsequent 6-month period following the index A1C, and changes in diabetes therapy were evaluated for evidence of “intensification” (e.g. increase in OAD dose, addition of another OAD, addition of a glucagon-like peptide 1 receptor agonist, or addition of insulin). Almost two-thirds of patients had no evidence of intensification in their antihyperglycemic therapy during the 6 months following the index A1C ≥7%, suggestive of above target glycemic control. Most alarming was the finding that even among patients in the highest index A1C category (≥9%) therapy was not intensified in 44% of patients, and slightly more than half (53%) of those with an A1C between 8 and 8.9% did not have their therapy intensified!

Why is this important?

The unavoidable conclusion from these data, that represent only one institution, is that physicians are not responding quickly enough to evidence of above target glycemic control in a high percentage of patients, even in those with HbA1c levels far exceeding typical treatment targets. Clearly, more work needs to be done to educate on the importance of ‘treating-to-target’, but targets tend to be point-in-time measurements such as what percentage of patients in a physician’s care are above A1C of 9% (e.g. HEDIS). With more and more practices utilizing electronic health records (EHRs), one way to help lessen clinical inertia and optimize intensification of therapy would be to not only have the EHRs automatically identify individuals that have an A1C above target, but add an alert when a subsequent A1C is still above target, and perhaps generate a report that goes to the organization to which the physician belongs. Do you have a method to identify patients above target, or above target for more than one measurement?

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