Clinical Inertia Common in Uncontrolled Diabetes Patients


Clinical inertia, which can be defined as "failure of healthcare providers to initiate or escalate therapy when indicated," is common in a large study of patients with uncontrolled type 2 diabetes.

"The surprising or maybe not surprising finding is that action was observed in 90% of patients, but only 56% of these patients came into glycemic control (HbA1c < 8.0%) within 2 years, with an average time of about 9 months," Elizabeth L. Ciemins, Ph.D., Director of Research & Analytics at the American Medical Group Association (AMGA) in Alexandria, Virginia, reported in her talk.

Specifically, the researchers defined clinical inertia as not being prescribed a new class of diabetes medication or having persistent uncontrolled diabetes (HbA1c > 8.0%) in their study of outpatients in a large US national database.

One of the biggest barriers to overcoming clinical inertia is cost, Ciemins told, as insulin and newer diabetes drugs such as GLP-1 receptor agonists and SGLT-2 inhibitors are very expensive. Or perhaps clinicians are not following guidelines to the letter, such as those from the ADA, one physician from London, UK, speculated.   

"I find the term 'clinical inertia' to be value-laden. It implies 'Naughty doctor, you're not doing what your teacher is telling you to do,' with the teacher in this instance being the ADA," he said, to laughter from the audience.  

What if a clinician adhered more to the American College of Physicians (ACP) guidelines,"about which there has been much discussion, and which are much more flexible about comorbidity, age, and potential quality-adjusted life-years gained by lowering HbA1c," for example, in someone with a lot of comorbidities who is 75 years old, he said.

Moreover, did the researchers adjust for differences in income, he wondered. Ciemins replied that uncontrolled diabetes was more likely to persist in the patients who had a lower level of education or lived in poorer neighborhoods.

Many patient- and physician-level factors, she added, could be contributing to persistent uncontrolled glycemia. However, the study was not designed to determine the factors are driving clinical inertia, but documenting the problem merely.

"Clinicians always blame the patients, and the patients always blame the clinicians" for lack of glycemic control, she noted. "And both of them could blame the ADA," said the UK physician, to more laughter.

Are ADA Guidelines Being Followed?

ADA guidelines recommend escalating diabetes therapy every 3 months if the patient is not at target HbA1c levels, Ciemins explained, but several previous studies have suggested that many patients may not be receiving this recommended treatment escalation.

To overcome this clinical inertia, she suggested, healthcare systems should identify high performing clinics or individual providers," and then go have a conversation and figure out what they are doing differently than other clinics or providers in the same system to achieve better outcomes."