In type 2 diabetes, clinical inertia persists across health care organizations

Elizabeth Ciemins

ORLANDO, Fla. — For patients with type 2 diabetes, a large database analysis suggests a lack of clinical action in the 6 months after an HbA1c diagnosis of at least 8%, contradicting guidelines issued by the American Diabetes Association, according to a speaker here.

“Clinical inertia, or the ‘failure of health care providers to initiate or escalate therapy when indicated,’ continues to occur among patients with type 2 diabetes who are receiving regular health care services,” Elizabeth Ciemins, PhD, MPH, MA, director of research and analytics at American Medical Group Association, a nonprofit trade association representing 440 medical groups and 175,000 physicians, told Endocrine Today. “Within 2 years, 11% of a cohort of bolus insulin-naive patients with uncontrolled glycemia (an HbA1c of at least 8%) who received regular health care had received no additional therapies. Patients on more or second- or third-line therapies were the least likely to receive the appropriate escalation of medications recommended by ADA guidelines. Additionally, black patients were less likely to receive treatment vs. white patients.”

The potential causes of clinical inertia are multifactorial, Ciemins said during a presentation at the American Diabetes Association Scientific Sessions, with issues affecting the initiation or escalation of therapy at the research, guidelines, system, provider and patient levels. From the provider’s standpoint, issues include an awareness of guidelines, time spent with the patient and a smoothly functioning care team, whereas the patient may express concerns about side effects, bad press related to specific medications, insurance coverage or faith in their providers or the health system, Ciemins said. Additionally, clinical inertia must be balanced with overtreatment and over-testing, she said.

“Providers are trying to balance paying attention to the acute and chronic needs of their patients with very little time,” Ciemins said. “They might not follow the guidelines because they can’t address everything at every visit.”

In a retrospective database analysis, Ciemins and colleagues assessed 22 million patient records across 22 health care organizations, analyzing 281,000 adult patients during a 5.5-year study period (January 2012 to June 2017). Included patients (mean age, 58 years; 43.4% women; mean BMI, 35.3 kg/m²; 11.4% black) had an outpatient visit in the last 12 months of the study period, an HbA1c measurement in the last 24 to 30 months (index HbA1c), and a diagnosis of type 2 diabetes on a claim or electronic health records problem list at least 6 months before index HbA1c. Researchers also analyzed a subset of 47,693 patients with an index HbA1c f at least 8% and a prior HbA1c of at least 8% or lack thereof for four 6-month follow-up periods for actions, including a new class of diabetes medication prescribed or an HbA1c of less than 8%. Researchers defined clinical inertia as the absence of an observable action following the index HbA1c.

Researchers found that 6 months after an index HbA1c of at least 8%, 55% of patients received no observable clinical action, ranging from 45% to 65% across health care organizations and between 18% and 96% across individual providers.

A new diabetes prescription was observed in 35% of patients (7.5% moved into glycemic control, defined as an HbA1c of less than 8%) and 10% moved into glycemic control without a new prescription, Ciemins said. Patient characteristics associated with increased clinical inertia during the 6- and 24-month follow-up periods included black race, low-income insurance, normal BMI and prescription for bolus insulin therapy (P < .01 for all). Within 24 months, clinical inertia was reduced to 19%, ranging from 13% to 28% across health care organizations, Ciemins said.
Ciemins said patients prescribed multiple therapies or those prescribed second- or third-line therapies were less likely to have experienced an escalation of therapy, and that titration of insulin dose cannot completely explain this finding over 2 years. Differences between races also persisted for 2 years, she said.

“Despite the finding that nearly 90% of patients received treatment within 2 years, only 56% of these patients came into glycemic control within the 2-year follow-up period, ranging from 46% to 66% across 22 health care organizations,” Ciemins said in an interview. “Variation in potential clinical inertia was observed across these 22 systems ranging from 7% to 19%; at the provider level, the variation ranged from 19% to 73%.”

Ciemins said greater rates of clinical inertia among those with low-income insurance and minority populations suggests potential populations to target to ensure adequate treatment for diabetes. Additionally, the decline in clinical inertia within 24 months suggests actions not seen in the data or later interventions that were ultimately effective. – by Regina Schaffer

Reference:

Ciemins EL, et al. 1-OR. Presented at: American Diabetes Association 78th Scientific Sessions; June 22-26, 2018; Orlando, Fla.

Disclosures: Novo Nordisk supported this study. Please see the abstract for the authors’ relevant financial disclosures.