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Chronic disease registries identify predictors of clinical inertia in diabetes
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AUSTIN, Texas — In patients with type 2 diabetes, infrequent visits with a primary care physician, delayed dose titration of insulin, and poor medication and nutrition management are predictors of clinical inertia, Wael Emad Eid, MD, FACP, FACE, CDE, said during a presentation here.
In an analysis of electronic health records using a clinical decision support tool, Eid, an associate professor at the University of South Dakota Sanford School of Medicine, said provider-related factors were the most important determinants of clinical inertia in diabetes, while noting that surrogate markers that predict clinical inertia are not independent of one another.
“The further the time until [patients] see the endocrinologist or a primary care physician and the less frequent the visits with primary care in the past, the more likely these patients will have a higher HbA1c,” said Eid, speaking at the American Association of Clinical Endocrinologists Scientific and Clinical Sessions. “This is important — a lot of these patients are getting missed, and we’re not capturing them.”
In a retrospective, cross-sectional study, Eid and colleagues analyzed electronic health records from 44,055 patients with type 2 diabetes enrolled in an electronic diabetes registry in a metropolitan health system for at least 6 months, going back to 2012. Researchers assessed last available HbA1c, LDL cholesterol and mean arterial blood pressure as surrogate measures for diabetes-related clinical inertia, and they measured patient-, provider- or system-related factors that may contribute to inertia using logistic regression for the cohort and subgroups based on HbA1c at enrollment. Patient-related factors included age, sex, insurance carrier, medications, ED and hospital visits, and vital signs; provider-related factors included last contact and next scheduled office visit; system-related factors included health care affiliation, patient portal and personal health record. Patients determined to have clinical inertia were compared with patients with baseline HbA1c 8% or less, LDL cholesterol 100 mg/dL or less and mean arterial blood pressure 107 mm Hg or less (controls). Primary outcomes were magnitude and determinants of clinical inertia.
Within the cohort, 19% had HbA1c at least 8%; 25% of patients had LDL cholesterol at least 100 mg/dL; 7.6% had mean arterial pressure at least 107 mm Hg.
When looking at patient-related factors, Eid noted that age and sex play a role in surrogate markers: Younger men tended to have higher HbA1c, LDL cholesterol and mean arterial pressure. In addition, patients with higher baseline HbA1c tended to have higher last readings for HbA1c, LDL cholesterol and mean arterial pressure (P < .01). Patients prescribed insulin therapy also tended to have higher last HbA1c values vs. those not using insulin, and longer duration of insulin or metformin use did not protect against higher HbA1c, Eid said.
Statin therapy was associated with better last LDL cholesterol and better last mean arterial pressure; however, statin therapy was also associated with higher last HbA1c when baseline HbA1c 8% or lower, Eid said (P < .01).
“The effect of the high HbA1c, [mean arterial pressure], LDL cholesterol — those three factors — they are all connected,” Eid said. “If you have one variable that is uncontrolled, it becomes undetermined for the other variables as well.”
But Eid noted that infrequent patient visits with clinicians also played a large role in clinical inertia.
“With regard to clinical inertia for HbA1c, it is complex,” Eid said. “It is not only [the role of] medications, it is not having future visits scheduled with the [primary care physician] or endocrinologist, or having less frequent visits with the primary care physician in the past. Being on insulin for long periods of time does not mean it’s going to get better. You really need to titrate those medications. Plus [there are] other factors.”
Eid noted that frequent and recent endocrinology visits predicted better HbA1c and better LDL cholesterol levels regardless of baseline HbA1c (P < .01). Frequent primary care visits were associated with improvement in HbA1c only when baseline HbA1c was between 8 and 9%, he said (P < .05).
For system-related factors, having a provider affiliated with the health care system was associated with lower last HbA1c mainly when the enrollment HbA1c was more than 9%, Eid said (P < .01). Having no access to personal health records was also associated with higher HbA1c when baseline HbA1c was at least 9%.
“When you plan a program for intervening for clinical inertia, you really have to focus on determinants with the aid of the clinical decision support that we currently have in the electronic medical records,” Eid said. – by Regina Schaffer
Reference:
Eid W; McCreless T. ABSTRACT #251. AACE Annual Scientific and Clinical Congress; May 3-7, 2017; Austin, Texas.
Disclosures: Eid reports receiving speaking fees and honoraria from Amgen and Sanofi.
for the subgroups based on HbA1c at enrollment
higher last HbA1c (P<0.01) compared to those who are
significant impact on diabetes care.