Clinical inertia in the treatment of hyperglycemia in type 2 diabetes patients in primary care

Abstract

Objective:

To assess clinical inertia, defined as failure to intensify antidiabetic treatment of patients who have not achieved the HbA_1c therapeutic goal (≤7%).

Research design and methods:

Multicenter cross-sectional study. Clinical inertia was assessed in a random sample of type 2 diabetes mellitus (T2DM) patients seen in primary care centers.

Results:

A total of 2783 patients (51.3% males; mean age: 68 [±11.5] years; diabetes duration: 7.1 [±5.6] years; mean HbA_1c: 6.8 [±1.5]) were analyzed. Of those, 997 (35.8%) had HbA_1c >7%. Treatment was intensified in 66.8% and consisted of: dose increase (40.5%); addition of oral antidiabetic (45.8%); or insulin treatment initiation (3.7%). Mean HbA_1c values in patients for whom treatment was intensified vs. non-intensified were 8.4% (±1.2) vs. 8.2% (±1.2), p < 0.05. Clinical inertia was detected in 33.2% of patients and diminished along with treatment complexity: lifestyle changes only (38.8%), oral monotherapy (40.3%), combined oral antidiabetics (34.5%), insulin monotherapy (26.1%) and combination of insulin and oral antidiabetics (21.4%). Clinical inertia decreased as HbA_1c increased: 37.3% for HbA_1c values ranging between 7.1%–8%; 29.4% for the 8.1%–9% HbA_1c range and 27.1% for HbA_1c ≥9%. Multivariate analysis confirmed that diabetes duration, step of treatment and HbA_1c were related to inertia. For each unit of HbA_1c increase clinical inertia decreased 47% (OR: 0.53).

Limitations:

The retrospective design of the study precluded an accurate investigation about reasons for lack of intensification that could actually be justified by some patient conditions, especially patients’ lack of adherence.

Conclusions:

Clinical inertia affected one third of T2DM patients with poor glycemic control and was greater in patients treated with only lifestyle changes or oral monotherapy. Treatment changes were performed when mean HbA_1c values were 1.4 points above therapeutic goals.

Keywords::

• Clinical inertia
• Glycemic control
• Primary care
• Treatment intensification
• Type 2 diabetes mellitus

Transparency

Declaration of funding

The GEDAPS 2007 evaluation of inertia has received financial support from Merck Sharp & Dohme Spain and the Fundació d’Atenció Primària. Both sponsors have played no role in the conduction of the study.

M.M.-C., B.B.-B., P.R.-O., J.F.-N., J.M.P.-V., and G.C.-d.-T. participated in the conception and design of study, acquisition of data, analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be submitted. M.M.-C. is the guarantor of the manuscript, taking responsibility for the contents of the article.

Declaration of financial/other relationships

M.M.-C., B.B.-B., P.R.-O., J.F.-N., J.M.P.-V., M.S., and G.C.-d.-T. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships.

Acknowledgements

All the members of the GEDAPS group, physicians and nurses, without whose commitment to quality of care it would not have been possible to carry out this study (see Appendix). Thanks to Sofia Perea Pharm D PhD who provided medical writing support funded by Merck Sharpe & Dohme Spain, S.A.