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Lioté F, Constantin A, Dahan É, Quiniou JB, Frazier A, Sibilia J. A prospective survey on therapeutic inertia in psoriatic arthritis (OPTI'PsA). Rheumatology (Oxford) 2024; 63:516-524. [PMID: 37261843 PMCID: PMC10836978 DOI: 10.1093/rheumatology/kead262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/27/2023] [Accepted: 05/19/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVES Clinical inertia, or therapeutic inertia (TI), is the medical behaviour of not initiating or intensifying treatment when recommended by clinical recommendations. To our knowledge, our survey is the first to assess TI around psoriatic arthritis (PsA). METHODS Eight hundred and twenty-five French rheumatologists were contacted via email between January and March 2021 and invited to complete an online questionnaire consisting of seven clinical vignettes: five cases ('oligoarthritis', 'enthesitis', 'polyarthritis', 'neoplastic history', 'cardiovascular risk') requiring treatment OPTImization, and two 'control' cases (distal interphalangeal arthritis, atypical axial involvement) not requiring any change of treatment-according to the most recent PsA recommendations. Rheumatologists were also questioned about their routine practice, continuing medical education and perception of PsA. RESULTS One hundred and one rheumatologists completed this OPTI'PsA survey. Almost half the respondents (47%) demonstrated TI on at least one of the five vignettes that warranted treatment optimization. The complex profiles inducing the most TI were 'oligoarthritis' and 'enthesitis' with 20% and 19% of respondents not modifying treatment, respectively. Conversely, clinical profiles for which there was the least uncertainty ('polyarthritis in relapse', 'neoplastic history' and 'cardiovascular risk') generated less TI with 11%, 8% and 6% of respondents, respectively, choosing not to change the current treatment. CONCLUSION The rate of TI we observed for PsA is similar to published data for other chronic diseases such as diabetes, hypertension, gout or multiple sclerosis. Our study is the first to show marked clinical inertia in PsA, and further research is warranted to ascertain the reasons behind this inertia.
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Affiliation(s)
- Frédéric Lioté
- Université Paris Cité, UFR de Médecine, Paris, France
- Rheumatology Department & INSERM U1132 Bioscar, Viggo Petersen Centre, Lariboisière Hospital, Paris, France
| | - Arnaud Constantin
- Rheumatology Department, Pierre-Paul Riquet Hospital, Toulouse, France
- Université Toulouse III—Paul Sabatier & INSERM, 1291 Infinity, Toulouse, France
| | - Étienne Dahan
- Rheumatology Department, UF 6501, Hautepierre Hospital, CHU Strasbourg, France
| | | | - Aline Frazier
- Rheumatology Department & INSERM U1132 Bioscar, Viggo Petersen Centre, Lariboisière Hospital, Paris, France
| | - Jean Sibilia
- Rheumatology Department, National Reference Centre for Rare Systemic Auto-immune Diseases East-South-West (RESO), CHU Strasbourg, France
- Molecular Immuno-Rhumatology Laboratory, GENOMAX platform, INSERM UMR-S1109, Faculty of Medicine, Interdisciplinary Thematic Institute (ITI) of Precision Medicine of Strasbourg, Transplantex NG, Federation of Translational Medicine of Strasbourg (FMTS), University of Strasbourg, Strasbourg, France
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Swat SA, Helmkamp LJ, Tietbohl C, Thompson JS, Fitzgerald M, McIlvennan CK, Harger G, Ho PM, Ahmad FS, Ahmad T, Buttrick P, Allen LA. Clinical Inertia Among Outpatients With Heart Failure: Application of Treatment Nonintensification Taxonomy to EPIC-HF Trial. JACC Heart Fail 2023; 11:1579-1591. [PMID: 37589610 DOI: 10.1016/j.jchf.2023.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear. OBJECTIVES This study examined reasons for GDMT nonintensification and characterized clinical inertia. METHODS In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase. RESULTS Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification. CONCLUSIONS In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse.
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Affiliation(s)
- Stanley A Swat
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura J Helmkamp
- Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Caroline Tietbohl
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jocelyn S Thompson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Monica Fitzgerald
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Colleen K McIlvennan
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Geoffrey Harger
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - P Michael Ho
- Rocky Mountain VA Regional Medical Center, Aurora, Colorado, USA
| | - Faraz S Ahmad
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tariq Ahmad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter Buttrick
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Adult and Child Center for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA.
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Page RL, Chow SL. Polypharmacy and the Clinical Inertia Conundrum for GDMT. JACC Heart Fail 2023; 11:1518-1520. [PMID: 37768247 DOI: 10.1016/j.jchf.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Robert L Page
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Sheryl L Chow
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, College of Pharmacy, Pomona, California, USA; Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, Orange, California, USA.
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Almigbal TH, Alzarah SA, Aljanoubi FA, Alhafez NA, Aldawsari MR, Alghadeer ZY, Alrasheed AA. Clinical Inertia in the Management of Type 2 Diabetes Mellitus: A Systematic Review. Medicina (Kaunas) 2023; 59. [PMID: 36676805 DOI: 10.3390/medicina59010182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023]
Abstract
This review seeks to establish, through the recent available literature, the prevalence of therapeutic intensification delay and its sequences in poorly controlled Type 2 Diabetes Mellitus (T2DM) patients. The strategy identified studies exploring the clinical inertia and its associated factors in the treatment of patients with T2DM. A total of 25 studies meeting the pre-established quality criteria were included in this review. These studies were conducted between 2004 and 2021 and represented 575,067 patients diagnosed with T2DM. Trusted electronic bibliographic databases, including Medline, Embase, and the Cochrane Central Register of Controlled Trials, were used to collect studies by utilizing a comprehensive set of search terms to identify Medical Subject Headings (MeSH) terms. Most o the studies included in this review showed clinical inertia rates over 50% of T2DM patients. In the USA, clinical inertia ranged from 35.4% to 85.8%. In the UK, clinical inertia ranged from 22.1% to 69.1%. In Spain, clinical inertia ranged from 18.1% to 60%. In Canada, Brazil, and Thailand, clinical inertia was reported as 65.8%, 68%, and 68.4%, respectively. The highest clinical inertia was reported in the USA (85.8%). A significant number of patients with T2DM suffered from poor glycemic control for quite a long time before treatment intensification with oral antidiabetic drugs (OADs) or insulin. Barriers to treatment intensification exist at the provider, patient, and system levels. There are deficiencies pointed out by this review at specialized centers in terms of clinical inertia in the management of T2DM including in developed countries. This review shows that the earlier intensification in the T2DM treatment is appropriate to address issues around therapeutic inertia.
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Alhagawy AJ, Yafei S, Hummadi A, Abutaleb R, Hakamy M, Alzughbi T, Gharawi N, Moafa M, Mokali A, Alhiqwy I, Altherwi M. Barriers and Attitudes of Primary Healthcare Physicians to Insulin Initiation and Intensification in Saudi Arabia. Int J Environ Res Public Health 2022; 19:16794. [PMID: 36554673 PMCID: PMC9779059 DOI: 10.3390/ijerph192416794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023]
Abstract
Saudi Arabia is a country with high prevalence of diabetes, uncontrolled diabetes, and diabetes-related complications. Poor glycemic control is multifactorial and could be explained in part by physician and patient reluctance toward insulin or insulin inertia. This study aimed to address physician barriers toward insulin therapy in primary care settings. It included 288 physicians from 168 primary healthcare centers (PHC) in the Jazan region of Saudi Arabia. Participants responded to questionnaire investigating physicians' attitude and barriers to insulin initiation and intensification in PHCs. In physician opinion, the most common barriers among their patients were fear of injection, lack of patient education, fear of hypoglycemia, and difficult administration. Physicians were reluctant to initiate insulin for T2D patients mostly due to patient non-adherence to blood sugar measurement, non-adherence to appointment or treatment, elderly patients, or due to patient refusal. Physicians' fear of hypoglycemia, lack of staff for patient education, and lack of updated knowledge were the primary clinician-related barriers. Exaggerated fears of insulin side effects, patient non-adherence, limited staff for patient's education, patient refusal, and inadequate consultation time were the main barriers to insulin acceptance and prescription.
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Affiliation(s)
- Ali Jaber Alhagawy
- Jazan Endocrinology & Diabetes Center, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Saeed Yafei
- Jazan Endocrinology & Diabetes Center, Ministry of Health, Jazan 45142, Saudi Arabia
- Faculty of Medicine and Health Sciences, Taiz University, Taiz P.O. Box 6803, Yemen
| | - Abdulrahman Hummadi
- Jazan Endocrinology & Diabetes Center, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Raed Abutaleb
- Jazan Endocrinology & Diabetes Center, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Mohammed Hakamy
- Family Medicine, Jazan Health Affairs, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Turki Alzughbi
- Jazan Endocrinology & Diabetes Center, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Nabeel Gharawi
- Family Medicine, Jazan Health Affairs, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Manal Moafa
- Family Medicine, Jazan Health Affairs, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Asma Mokali
- Family Medicine, Jazan Health Affairs, Ministry of Health, Jazan 45142, Saudi Arabia
| | - Ibrahim Alhiqwy
- Faculty of Medicine, Jazan University, Jazan 45142, Saudi Arabia
| | - Mousa Altherwi
- Nursing Department, Ministry of Health, Jazan 45142, Saudi Arabia
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Jauffret C, Ottaviani S, Latourte A, Ea HK, Graf S, Lioté F, Bardin T, Richette P, Pascart T. Simple Application and Adherence to Gout Guidelines Enables Disease Control: An Observational Study in French Referral Centres. J Clin Med 2022; 11. [PMID: 36233609 DOI: 10.3390/jcm11195742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background: In a context of therapeutic inertia, the French Society of Rheumatology (SFR) published its first recommendations on gout in 2020, which were deliberately simple and concise. The objectives of the study were to determine the profile of patients referred to French gout-expert centres, and to examine the results of their management and the factors leading to those results. Methods: Three hundred patients attending a first visit for gout management in three French referral centres were retrospectively and randomly included in this multicentre observational study. Visits were performed at baseline (M0) and scheduled for month 6 (M6), month 12 (M12), and month 24 (M24). Results: Patients were 81% male and had a mean age 62.2 ± 15.2 years. Management followed French recommendations after the baseline visit in 94.9% of cases. SU levels were below 6.0 mg/dL in 59.4% of patients at M6, 67.9% at M12, and 78.6% at M24, with increasing clinical improvement (i.e., flare decrease) over 2 years of follow-up. At M24, 50% of patients were treated with allopurinol (313 ± 105 mg/d), which exceeded renal restrictions of doses in 61.5% of them, and 48.2% received febuxostat (84 ± 36 mg/d). The need for a sufficient dosage of ULT was the only predictive factor found for successful achievement of SU levels < 6.0 mg/dL at a given visit. Conclusions: Simple application of gout-management guidelines is feasible in clinical practice and is efficient, with a majority of patients achieving SU targets and clinical improvement.
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Isajev N, Bjegovic-Mikanovic V, Bukumiric Z, Vrhovac D, Lalic NM. Predictors of Clinical Inertia and Type 2 Diabetes: Assessment of Primary Care Physicians and Their Patients. Int J Environ Res Public Health 2022; 19:4436. [PMID: 35457303 DOI: 10.3390/ijerph19084436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022]
Abstract
With the growing prevalence and complex pathophysiology of type 2 diabetes, many patients fail to achieve treatment goals despite guidelines and possibilities for treatment individualization. One of the identified root causes of this failure is clinical inertia. We explored this phenomenon, its possible predictors, and groups of patients affected the most, together with offering potential paths for intervention. Our research was a cross-sectional study conducted during 2021 involving 52 physicians and 543 patients of primary healthcare institutions in Belgrade, Serbia. The research instruments were questionnaires based on similar studies, used to collect information related to the factors that contribute to developing clinical inertia originating in both physicians and patients. In 224 patients (41.3%), clinical inertia was identified in patients with poor overall health condition, long diabetes duration, and comorbidities. Studying the changes made to the treatment, most patients (53%) had their treatment adjustment more than a year ago, with 19.3% of patients changing over the previous six months. Moreover, we found significant inertia in the treatment of patients using modern insulin analogues. Referral to secondary healthcare institutions reduced the emergence of inertia. This assessment of primary care physicians and their patients pointed to the high presence of clinical inertia, with an overall health condition, comorbidities, diabetes duration, current treatment, last treatment change, glycosylated hemoglobin and fasting glucose measuring frequency, BMI, patient referral, diet adjustment, and physician education being significant predictors.
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Castro-Dominguez Y, Trejo Paredes MC, Mones P, Spatz ES, Lombo B, Sepulveda P, Reyes-Uribe O, Otero J, Ramirez G, Urena P, Lopez E, Dominguez B, McNamara RL. Patient Awareness and Clinical Inertia: Obstacles to Hypertension Control in Rural Communities in the Dominican Republic. Am J Hypertens 2021; 34:939-947. [PMID: 33822861 DOI: 10.1093/ajh/hpab054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/07/2021] [Accepted: 04/02/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Many obstacles exist for adequate hypertension control, including low individual awareness and clinical inertia (CI). In this study, we aimed to determine hypertension prevalence, awareness, treatment, and control among community residents of rural areas of Peravia in Dominican Republic (DR), followed by an assessment of CI in their primary care clinics (PCCs). METHODS We interviewed 827 adults from 8 rural communities of Peravia. Demographics, medical history, health care information, and blood pressure (BP) were obtained. We reviewed the community PCC visits of patients with known hypertension or a BP ≥140/90, abstracting medical history and the physician's action toward uncontrolled BP. RESULTS Of those interviewed, 57% (95% CI: 53%-60%) had hypertension, with 63% (95% CI: 59%-68%) of those aware of their diagnosis. Among individuals with hypertension, 60% (95% CI: 56%-65%) were receiving pharmacological treatment, and only 35% (95% CI: 31%-40%) were controlled. Characteristics associated with awareness were female sex, age >55 years, diabetes, private insurance, and having at least 1 health care visit within the past year. Of the 507 PCC patients reviewed, 340 (67%) had uncontrolled BP. Of these, 220 had no clinical action to address the uncontrolled BP, corresponding to a CI rate of 65%. CONCLUSIONS Among rural communities in the DR, undiagnosed hypertension remains common, especially in individuals who are younger, uninsured, or with limited access to health care. For those seen in PCCs, therapeutic intensification to achieve controlled BP is infrequently done. Strategies to address population awareness and CI are needed to improve hypertension control.
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Affiliation(s)
- Yulanka Castro-Dominguez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maria Camila Trejo Paredes
- Department of Internal Medicine, School of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Patricia Mones
- School of Medicine, Instituto Tecnologico de Santo Domingo, Santo Domingo, Dominican Republic
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bernardo Lombo
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Priscilla Sepulveda
- School of Medicine, Instituto Tecnologico de Santo Domingo, Santo Domingo, Dominican Republic
| | - Olmar Reyes-Uribe
- School of Medicine, Instituto Tecnologico de Santo Domingo, Santo Domingo, Dominican Republic
| | - Jorge Otero
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gisselle Ramirez
- School of Medicine, Instituto Tecnologico de Santo Domingo, Santo Domingo, Dominican Republic
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Pedro Urena
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Emilton Lopez
- School of Medicine, Instituto Tecnologico de Santo Domingo, Santo Domingo, Dominican Republic
| | - Boanerges Dominguez
- School of Medicine, Instituto Tecnologico de Santo Domingo, Santo Domingo, Dominican Republic
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Background Although severe hypercholesterolemia confers a 5‐fold increased long‐term risk for coronary artery disease, treatment guidelines may not be fully implemented, leading to underdiagnosis and suboptimal treatment. To further understand the clinical features and gaps in treatment approaches, we analyzed electronic medical record data from a midwestern US multidisciplinary healthcare system, between 2009 and 2020. Methods and Results We retrospectively assessed the prevalence, clinical presentation, and treatment characteristics of individuals currently treated with statin therapy having a low‐density lipoprotein cholesterol (LDL‐C) value that is either (1) an actual maximum electronic medical record–documented LDL‐C ≥190 mg/dL (group 1, n=7542) or (2) an estimated pretreatment LDL‐C ≥190 mg/dL (group 2, n=7710). Comorbidities and prescribed lipid‐lowering therapies were assessed. Statistical analyses identified differences among individuals within and between groups. Of records analyzed (n=266 282), 7% met the definition for primary severe hypercholesterolemia. Group 1 had more comorbidities than group 2. More individuals in both groups were treated by primary care providers (49.8%–53.0%, 32.6%–36.4%) than by specialty providers (4.1%–5.5%, 2.1%–3.3%). High‐intensity lipid‐lowering therapy was prescribed less frequently for group 2 than for group 1, but moderate‐intensity statins were prescribed more frequently for group 2 (65%) than for group 1 (52%). Conclusions Two percent of patients in our study population being treated with low‐ or moderate‐intensity statins have an estimated LDL‐C ≥190 mg/dL (indicating severe hypercholesterolemia), but receive less aggressive treatment than patients with a maximum measured LDL‐C ≥190 mg/dL.
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Affiliation(s)
- Wael E Eid
- St. Elizabeth Physicians Regional Diabetes Center Covington KY.,University of Kentucky College of Medicine Lexington KY.,University of South Dakota Sanford School of Medicine Sioux Falls SD.,Faculty of Medicine University of Alexandria Alexandria Egypt
| | | | - Elijah Flerlage
- Department of Mathematics and Statistics Northern Kentucky University Highland Heights KY
| | - Joseph R Nolan
- Department of Mathematics and Statistics Northern Kentucky University Highland Heights KY
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Meredith AH, Buatois EM, Krenz JR, Walroth T, Shenk M, Triboletti JS, Pence L, Gonzalvo JD. Assessment of clinical inertia in people with diabetes within primary care. J Eval Clin Pract 2021; 27:365-370. [PMID: 32548871 DOI: 10.1111/jep.13429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Clinical inertia, defined as a delay in treatment intensification, is prevalent in people with diabetes. Treatment intensification rates are as low as 37.1% in people with haemoglobin A1c (HbA1c) values >7%. Intensification by addition of medication therapy may take 1.6 to more than 7 years. Clinical inertia increases the risk of cardiovascular events. The primary objective was to evaluate rates of clinical inertia in people whose diabetes is managed by both pharmacists and primary care providers (PCPs). Secondary objectives included characterizing types of treatment intensification, HbA1c reduction, and time between treatment intensifications. METHOD Retrospective chart review of persons with diabetes managed by pharmacists at an academic, safety-net institution. Eligible subjects were referred to a pharmacist-managed cardiovascular risk reduction clinic while continuing to see their PCP between October 1, 2016 and June 30, 2018. All progress notes were evaluated for treatment intensification, HbA1c value, and type of medication intensification. RESULTS Three hundred sixty-three eligible patients were identified; baseline HbA1c 9.6% (7.9, 11.6) (median interquartile range [IQR]). One thousand one hundred ninety-two pharmacist and 1739 PCP visits were included in data analysis. Therapy was intensified at 60.5% (n = 721) pharmacist visits and 39.3% (n = 684) PCP visits (P < .001). The median (IQR) time between interventions was 49 (28, 92) days for pharmacists and 105 (38, 182) days for PCPs (P < .001). Pharmacists more frequently intensified treatment with glucagon-like peptide-1 agonists and sodium glucose cotransporter-2 inhibitors. CONCLUSION Pharmacist involvement in diabetes management may reduce the clinical inertia patients may otherwise experience in the primary care setting.
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Affiliation(s)
- Ashley H Meredith
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
| | - Emily M Buatois
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Texas Tech University Health Sciences Center, 5220 80th Street, Lubbock, TX, 79424, USA
| | - James R Krenz
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Todd Walroth
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
| | - McKenzie Shenk
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA.,Department of Pharmacy Practice, Cedarville University School of Pharmacy, 251 N Main St, Cedarville, OH, 45341, USA
| | - Jessica S Triboletti
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA.,Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, 4600 Sunset Ave, Indianapolis, IN, 46208, USA
| | - Lauren Pence
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
| | - Jasmine D Gonzalvo
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
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Kim BJ, Cho YJ, Hong KS, Lee J, Kim JT, Choi KH, Park TH, Park SS, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kim WJ, Shin DI, Sohn SI, Hong JH, Lee JS, Lee J, Han MK, Gorelick PB, Bae HJ. Treatment Intensification for Elevated Blood Pressure and Risk of Recurrent Stroke. J Am Heart Assoc 2021; 10:e019457. [PMID: 33787300 PMCID: PMC8174371 DOI: 10.1161/jaha.120.019457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background It remains unclear whether physicians' attitudes toward timely management of elevated blood pressure affect the risk of stroke recurrence. Methods and Results From a multicenter stroke registry database, we identified 2933 patients with acute ischemic stroke who were admitted to participating centers in 2011, survived at the 1‐year follow‐up period, and returned to outpatient clinics ≥2 times after discharge. As a surrogate measure of physicians' attitude, individual treatment intensification (TI) scores were calculated by dividing the difference between the frequencies of observed and expected medication changes by the frequency of clinic visits and categorizing them into 5 groups. The association between TI groups and the recurrence of stroke within 1 year was analyzed using hierarchical frailty models, with adjustment for clustering within each hospital and relevant covariates. Mean±SD of the TI score was −0.13±0.28. The TI score groups were significantly associated with increased risk of recurrent stroke compared with Group 3 (TI score range, −0.25 to 0); Group 1 (range, −1 to −0.5), adjusted hazard ratio (HR) 13.43 (95% CI, 5.95–30.35); Group 2 (range, −0.5 to −0.25), adjusted HR 4.59 (95% CI, 2.01–10.46); and Group 4 (TI score 0), adjusted HR 6.60 (95% CI, 3.02–14.45); but not with Group 5 (range, 0–1), adjusted HR 1.68 (95% CI, 0.62–4.56). This elevated risk in the lowest TI score groups persisted when confining analysis to those with hypertension, history of blood pressure‐lowering medication, no atrial fibrillation, and regular clinic visits and stratifying the subjects by functional capacity at discharge. Conclusions A low TI score, which implies physicians' therapeutic inertia in blood pressure management, was associated with a higher risk of recurrent stroke. The TI score may be a useful performance indicator in the outpatient clinic setting to prevent recurrent stroke.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology Ilsan Paik HospitalInje University Goyang Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology Ilsan Paik HospitalInje University Goyang Republic of Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Hospital Daegu Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Medical School and Hospital Gwangju Republic of Korea
| | - Kang Ho Choi
- Department of Neurology Chonnam National University Medical School and Hospital Gwangju Republic of Korea
| | - Tai Hwan Park
- Department of Neurology Seoul Medical Center Seoul Republic of Korea
| | - Sang-Soon Park
- Department of Neurology Seoul Medical Center Seoul Republic of Korea
| | - Jong-Moo Park
- Department of Neurology Eulji General Hospital Eulji University Seoul Republic of Korea
| | - Kyusik Kang
- Department of Neurology Eulji General Hospital Eulji University Seoul Republic of Korea
| | - Soo Joo Lee
- Department of Neurology Eulji University HospitalEulji University Daejeon Republic of Korea
| | - Jae Guk Kim
- Department of Neurology Eulji University HospitalEulji University Daejeon Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University College of Medicine Busan Republic of Korea
| | - Dae-Hyun Kim
- Department of Neurology Dong-A University College of Medicine Busan Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Mi-Sun Oh
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Wi-Sun Ryu
- Department of Neurology Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Jay Chol Choi
- Department of Neurology Jeju National University Jeju Republic of Korea
| | - Wook-Joo Kim
- Department of Neurology Ulsan University HospitalUniversity of Ulsan College of Medicine Ulsan Republic of Korea
| | - Dong-Ick Shin
- Department of Neurology Chungbuk National University Hospital Cheongju Republic of Korea
| | - Sung Il Sohn
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Republic of Korea
| | - Jeong-Ho Hong
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center Asan Medical Center Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
| | - Philip B Gorelick
- Davee Department of Neurology Northwestern University Feinberg School of Medicine Chicago IL
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
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Sico IP, Oberle A, Thomas SM, Barsanti T, Egbuonu-Davis L, Kennedy DT, Zullig LL, Bosworth HB. Therapeutic Inertia in Prescribing Biologics for Patients with Moderate-to-Severe Asthma: Workshop Summary. Patient Prefer Adherence 2021; 15:705-712. [PMID: 33854304 PMCID: PMC8039536 DOI: 10.2147/ppa.s303841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/19/2021] [Indexed: 01/22/2023] Open
Abstract
Moderate-to-severe asthma represents about a quarter of the nearly 10% of Americans diagnosed with asthma. Many patients with moderate-to-severe asthma have uncontrolled symptoms that lead to exacerbations requiring oral corticosteroids. There are many factors contributing to poor asthma control, including poor adherence to prescribed therapies, the under-prescribing of biologics and therapeutic inertia. We convened an eight-member panel from fields of primary care, pulmonology, immunology, health services and clinical research, behavioral science and pharmaceutical medical affairs, with the goal of identifying contributing factors and solutions to therapeutic inertia with asthma biologics. We used the Capability, Opportunity, and Motivation (COM-B) model to classify patient and provider behavior towards therapeutic inertia. The model incorporates existing behavior theories and is driven by the interaction of capability, opportunity, and motivation. We used a Delphi method to identify and develop six primary solutions: 1) integration of patient-centered outcomes into asthma management practice; 2) provider education about asthma treatment; 3) moderate-to-severe asthma care delivery redesign; 4) harmonized, evidence-based protocol for the management of moderate-to-severe asthma; 5) designated coordinator approach for optimal asthma management; and 6) a case coordination digital support tool. Integration of patient-centered outcomes into asthma management practice and provider education were identified as having the highest potential to impact therapeutic and clinical inertia. The COM-B model is effective in identifying improvement within therapeutic inertia targeting the capabilities, opportunities, and motivations of patients, providers, and payer systems.
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Affiliation(s)
- Isabelle P Sico
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, USA
| | - Amber Oberle
- Division of Pulmonary, Allergy and Critical Care, Duke University, Durham, NC, USA
| | | | | | | | | | - Leah L Zullig
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Correspondence: Hayden B Bosworth Duke University School of Medicine, 411 West Chapel Hill Street, Suite 600, Durham, NC, 27701, USATel +1 919-286-6936 Email
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Gupta VA, Alnabelsi TS, Shringi S, Leung SW, Sorrell VL. Cardiovascular Risk After Sepsis: Understanding the Role of Statin Indications and the Impact of Clinical Inertia on Prescribing Patterns. J Cardiovasc Pharmacol Ther 2020; 25:541-547. [PMID: 32551836 DOI: 10.1177/1074248420933395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Patients with sepsis have high rates of major adverse cardiovascular events (MACE) in the literature, but the stratification of those at risk has been limited. Statin indicated groups provides clear criteria for therapy, but the risk of MACE after sepsis based on these groups has never been assessed. MATERIALS AND METHODS This was a retrospective cohort analysis conducted on adult patients admitted from January 1, 2013, to December 31, 2013, with suspected or confirmed sepsis and data available on statin use. Patients' past medical history; statin use prior, during, or at time of discharge; and occurrence of MACE were recorded from electronic health records. RESULT A total of 321 patients were screened and 265 were found to have data available on statin use. The mean age of the patients was 59 ± 15 years and 47% were female. Overall, 9% were observed to have a MACE at 1 year, with significantly higher rates in those in a statin indicated group (12.2%). On admission, 174 patients were not taking a statin out of whom 52% were in a statin indicated group. Among those in a statin indicated group who survived to hospital discharge, only 10% not on a statin on admission received a statin on discharge, whereas 89% on a statin on admission received a statin on discharge. CONCLUSION There is a high risk of MACE after sepsis especially among those in statin indicated groups with significant clinical inertia in prescribing practices.
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Affiliation(s)
- Vedant A Gupta
- Gill Heart and Vascular Institute, 4530University of Kentucky, Lexington, KY, USA
| | - Talal S Alnabelsi
- Gill Heart and Vascular Institute, 4530University of Kentucky, Lexington, KY, USA
| | - Sandipan Shringi
- Samarth Nursing Home and Research Center (Medicine), Kota, Rajasthan, India
| | - Steve W Leung
- Gill Heart and Vascular Institute, 4530University of Kentucky, Lexington, KY, USA
| | - Vincent L Sorrell
- Gill Heart and Vascular Institute, 4530University of Kentucky, Lexington, KY, USA
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Bain SC, Bekker Hansen B, Hunt B, Chubb B, Valentine WJ. Evaluating the burden of poor glycemic control associated with therapeutic inertia in patients with type 2 diabetes in the UK. J Med Econ 2020; 23:98-105. [PMID: 31311364 DOI: 10.1080/13696998.2019.1645018] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background and aims: Effective glycemic control is the cornerstone of successful type 2 diabetes management. However, many patients fail to reach glycemic control targets, and therapeutic inertia (failure to intensify therapy to address poor glycemic control in a timely manner) has been widely reported. The aim of the present study was to evaluate the economic burden associated with diabetes-related complications due to poor glycemic control for patients with type 2 diabetes in the UK.Methods: A validated long-term model of type 2 diabetes (IQVIA CORE Diabetes Model) was used to project cost outcomes for a UK population with type 2 diabetes, based on data from The Health Improvement Network primary care database, at different levels of glycemic control. Costs associated with diabetes-related complications were accounted in 2017 Pounds Sterling (GBP). Complication costs were estimated for populations achieving different glycated hemoglobin (HbA1c) targets, in a number of delayed treatment intensification scenarios, and across a range of time horizons.Results: For patients with an HbA1c level of 8.2% (66 mmol/mol), 7 years in poor control could increase mean costs associated with diabetes-related complications by over GBP 690 per patient and lead to costs of over GBP 1,500 in lost workplace productivity compared with achieving good glycemic control (HbA1c 7.0%, 53 mmol/mol) over a 10-year time horizon. Based on published estimates of the proportion of type 2 diabetes patients failing to meet glycemic targets in the UK, this corresponds to an additional economic burden of ∼GBP 2,600 million (complication costs plus lost productivity costs).Conclusions: The economic burden of poor glycemic control in type 2 diabetes in the UK is substantial. Efforts to avoid therapeutic inertia could substantially reduce diabetes-related complication costs even in the short-term.
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Affiliation(s)
- Stephen C Bain
- Diabetes Research Unit Cyrmu, Swansea University Medical School, Swansea, UK
| | | | - Barnaby Hunt
- Health Economics, Ossian Health Economics and Communications, Basel, Switzerland
| | | | - William J Valentine
- Health Economics, Ossian Health Economics and Communications, Basel, Switzerland
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15
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Reach G. [Antihypertensive treatment: the human factor]. Rev Prat 2019; 69:1087-1090. [PMID: 32237578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Antihypertensive treatment: the human factor. Two barriers limit the effectiveness of treatment in chronic diseases: non-adherence by patients who do not take prescribed drugs and clinical inertia by physicians who do not follow good practice guidelines. Taking this "human factor" into account reveals the importance of the quality of the doctor-patient relationship. Both need to be considered as persons endowed with complex thought. This explains the advent in medicine of the concept of shared medical decision-making.
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Affiliation(s)
- Gérard Reach
- Direction Qualité et Droits des patients, groupe hospitalier Hôpitaux universitaires Paris-Seine-Saint-Denis, AP-HP, Bobigny, France Laboratoire Éducations et Pratiques de santé, Université Sorbonne Paris Cité-Paris-13, Bobigny, France
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16
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Kartoun U, Iglay K, Shankar RR, Beam A, Radican L, Chatterjee A, Pai JK, Shaw S. Factors associated with clinical inertia in type 2 diabetes mellitus patients treated with metformin monotherapy. Curr Med Res Opin 2019; 35:2063-2070. [PMID: 31337263 DOI: 10.1080/03007995.2019.1648116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: To assess demographic and clinical characteristics associated with clinical inertia in a real-world cohort of type 2 diabetes mellitus patients not at hemoglobin A1c goal (<7%) on metformin monotherapy.Methods: Adult (≥18 years) type 2 diabetes mellitus patients who received care at Massachusetts General Hospital/Brigham and Women's Hospital and received a new metformin prescription between 1992 and 2010 were included in the analysis. Clinical inertia was defined as two consecutive hemoglobin A1c measures ≥7% ≥3 months apart while remaining on metformin monotherapy (i.e. without add-on therapy). The association between clinical inertia and demographic and clinical characteristics was examined via logistic regression.Results: Of 2848 eligible patients, 43% did not achieve a hemoglobin A1c goal of <7% 3 months after metformin monotherapy initiation. A sub-group of 1533 patients was included in the clinical inertia analysis, of which 36% experienced clinical inertia. Asian race was associated with an increased likelihood of clinical inertia (OR = 2.43; 95% CI = 1.48-3.96), while congestive heart failure had a decreased likelihood (OR = 0.58; 95% CI = 0.32-0.98). Chronic kidney disease and cardiovascular/cerebrovascular disease had weaker associations but were directionally similar to congestive heart failure.Conclusions: Asian patients were at an increased risk of clinical inertia, whereas patients with comorbidities appeared to have their treatment more appropriately intensified. A better understanding of these factors may inform efforts to decrease the likelihood for clinical inertia.
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Affiliation(s)
- Uri Kartoun
- Center for Systems Biology, Center for Assessment Technology & Continuous Health (CATCH), Massachusetts General Hospital, Boston, MA, USA
- Faculty of Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Andrew Beam
- Faculty of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Stanley Shaw
- Center for Systems Biology, Center for Assessment Technology & Continuous Health (CATCH), Massachusetts General Hospital, Boston, MA, USA
- Faculty of Medicine, Harvard Medical School, Boston, MA, USA
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Wong I. Study of type 2 diabetes management among patients in a Macau primary care setting. Fam Med Community Health 2019; 7:e000031. [PMID: 32148710 PMCID: PMC6910744 DOI: 10.1136/fmch-2018-000031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 08/12/2019] [Accepted: 08/18/2019] [Indexed: 12/12/2022] Open
Abstract
Background In the primary care setting in Macau, type 2 diabetes mellitus (T2DM) is the seventh most common reason for consultation. Inadequate glycaemic control constitutes a major public health problem and is associated with premature death and disability and decreased quality of life. Moreover, this condition substantially increases healthcare expenditures. Objective The primary objective was to assess the successful glycaemic control rates, blood pressure (BP) and cholesterol control rates in patients with T2DM in a Macau primary care setting. The secondary objective of this study was to assess the delay of insulin initiation in the Sao Lourence Health Center. Methods Patients were stratified according to age (<65 years vs ≥65 years) and sex. Successful glycaemic control was defined as glycated haemoglobin (HbA1c) <7%. Successful cholesterol control was defined as a low-density lipoprotein cholesterol (LDL-C) level <2.6 mmol/L, and BP control was defined as BP <140/90 mm Hg. Results Among the 2157 participants included in this study, 1046 (48.5%) patients had HbA1c <7%, 1209 (56.1%) patients had BP <140/90 mm Hg and 1244 (57.7%) patients had LDL-C <2.6 mmol/L. In conclusion, only 403 (18.7%) patients met the targets for all three measures. Of the 235 patients who were on insulin therapy, the mean (±SD) duration from T2DM diagnosis to insulin initiation was 7.47±6.52 years, the mean (±SD) duration from HbA1c not meeting the target (HbA1c ≥7% over 1 year and persistently) to insulin initiation was 3.34±3.66 years and the mean baseline HbA1c was 9.13%. Compared with patients with a longer duration (≥5 years) of HbA1c not meeting the target before insulin initiation, those who started insulin within 1 year of HbA1c not meeting the target had a better glycaemic control rate (40.7% vs 13%). Conclusions Nearly half of the patients at Sao Lourence Health Center, a primary care centre in Macau, met the glycaemic control target, but less than one-fifth of patients met all three targets for T2DM control. Moreover, there was a delay in insulin initiation for people with T2DM.
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Affiliation(s)
- In Wong
- Health Bureau, Macau SAR Government, Macau, China
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18
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Raccah D, Guerci B, Ajmera M, Davis K, Meyers J, Lew E, Shaunik A, Blonde L. Clinical implications of prolonged hyperglycaemia before basal insulin initiation in type 2 diabetes patients: An electronic medical record database analysis. Endocrinol Diabetes Metab 2019; 2:e00061. [PMID: 31294079 PMCID: PMC6613234 DOI: 10.1002/edm2.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/23/2018] [Indexed: 11/09/2022] Open
Abstract
AIMS To assess the effect of duration of hyperglycaemia before basal insulin (BI) initiation on clinical outcomes in type 2 diabetes (T2D). MATERIALS AND METHODS Patients with T2D who initiated BI during 2009-2013, had continuous enrolment for ≥2 years preceding and ≥1 year following BI initiation ("index date"), and had ≥1 glycated haemoglobin (A1C) measure not at target (ie, ≥7.0%) within 6 months preindex date were included in the study. Patients were stratified by preindex-date duration of A1C ≥7.0%. Longitudinal A1C, weight, BMI, and diabetes medication were compared between cohorts for up to 15-month follow-up. RESULTS Of 37 053 patients who initiated BI, 40.7%, 15.3%, 16.0%, and 28.0%, respectively, had uncontrolled A1C for <6, 6-<12, 12-<18 and 18-24 months preindex date. Baseline characteristics were similar between cohorts. Baseline A1C values were similar across cohorts (9.2%-9.6%). Mean follow-up A1C values were higher with longer preindex-date duration of uncontrolled A1C (8.0 ± 1.7%, 8.2 ± 1.6%, 8.5 ± 1.7%, and 8.6 ± 1.7% for <6, 6-<12, 12-<18, and 18-24 months); attainment of A1C <7.0% worsened with increasing preindex-date duration of A1C ≥7.0% (29.6%, 20.0%, 14.6%, and 11.5% for <6, 6-<12, 12-<18, and 18-24 months). CONCLUSIONS These data suggest that longer duration of uncontrolled A1C before BI initiation increases the risk of not reaching glycaemic targets. However, target attainment was poor in all cohorts, highlighting inadequate glycaemic control as an important unmet need in US patients with T2D.
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Affiliation(s)
- Denis Raccah
- University Hospital Sainte MargueriteMarseilleFrance
| | - Bruno Guerci
- Diabetology DepartmentUniversity of LorraineVandoeuvre‐Lès‐NancyFrance
| | | | | | | | | | | | - Lawrence Blonde
- Department of Endocrinology, Frank Riddick Diabetes InstituteOchsner Medical CenterNew OrleansLouisiana
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Correa MF, Li Y, Kum HC, Lawley MA. Assessing the Effect of Clinical Inertia on Diabetes Outcomes: a Modeling Approach. J Gen Intern Med 2019; 34:372-378. [PMID: 30565149 PMCID: PMC6420509 DOI: 10.1007/s11606-018-4773-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/10/2018] [Accepted: 11/21/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND There are an increasing number of newer and better therapeutic options in the management of diabetes. However, a large proportion of diabetes patients still experience delays in intensification of treatment to achieve appropriate blood glucose targets-a phenomenon called clinical inertia. Despite the high prevalence of clinical inertia, previous research has not examined its long-term effects on diabetes-related health outcomes and mortality. OBJECTIVE We sought to examine the impact of clinical inertia on the incidence of diabetes-related complications and death. We also examined how the impact of clinical inertia would vary by the length of treatment delay and population characteristics. DESIGN We developed an agent-based model of diabetes and its complications. The model was parameterized and validated by data from health surveys, cohort studies, and trials. SUBJECTS We studied a simulated cohort of patients with diabetes in San Antonio, TX. MAIN MEASURES We examined 25-year incidences of diabetes-related complications, including retinopathy, neuropathy, nephropathy, and cardiovascular disease. KEY RESULTS One-year clinical inertia could increase the cumulative incidences of retinopathy, neuropathy, and nephropathy by 7%, 8%, and 18%, respectively. The effects of clinical inertia could be worse for populations who have a longer treatment delay, are aged 65 years or older, or are non-Hispanic whites. CONCLUSION Clinical inertia could result in a substantial increase in the incidence of diabetes-related complications and mortality. A validated agent-based model can be used to study the long-term effect of clinical inertia and, thus, inform clinicians and policymakers to design effective interventions.
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Affiliation(s)
- Maria F Correa
- Department of Psychiatry, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Yan Li
- Center for Health Innovation, The New York Academy of Medicine, New York, NY, USA. .,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Hye-Chung Kum
- Department of Health Policy and Management, Texas A&M University, College Station, TX, USA.,Center for Remote Health Technologies and Systems, Texas A&M University, College Station, TX, USA.,Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, USA
| | - Mark A Lawley
- Center for Remote Health Technologies and Systems, Texas A&M University, College Station, TX, USA.,Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, USA
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Abstract
Clinical inertia is common in all chronic diseases, including diabetes. Despite the advent of newer agents for the management of hyperglycemia, hypertension, and dyslipidemia, the number of people with diabetes hitting all three targets remains small. The causes of clinical inertia are multifactorial, with contributory elements from people with diabetes, physicians, and the system within which they work. Every health care provider should have the best interest of their patients at heart; most people with diabetes want to maintain their health for as long as possible, and the maintenance of good health is not only the purpose of the system, but also the most cost-effective strategy. It is the thesis of this article that a potential reversible contributor to clinical inertia is the communication among these individual elements, which can be called "coproduction." The coproduction model of open communication encourages discourse, allowing the person with diabetes to understand their diagnosis and therefore better engage in treatment options. Improving engagement allows the healthcare team, including the physician and the person with diabetes, to establish shared goals that are important to all team members and to agree to acceptable side effects or risks of interventions in order to achieve these goals. Everyone needs to acknowledge that non-adherence exists and can be an issue, thereby allowing reasons to be explored. Only once the person with diabetes is allowed to take full ownership of their disease and actively participate in decision making can they take control of their disease, thereby improving outcomes.
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Affiliation(s)
- Carmen Soto
- Academic Paediatrics, University College London Hospital, London, UK
| | - William David Strain
- Diabetes and Vascular Research & Academic Department of Geriatric Medicine, University of Exeter Medical School, Exeter, UK
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Jabbar A, Mohamed WMIBW, Ozaki R, Mirasol R, Treuer T, Lew T, Qi R, Sheu WHH, Deerochanawong C, Babineaux SM. Patterns and trends in insulin initiation and intensification among patients with type 2 diabetes mellitus in the Western Pacific region. Curr Med Res Opin 2018; 34:1653-1662. [PMID: 29863422 DOI: 10.1080/03007995.2018.1484712] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Current and future estimates of the burden of diabetes for the Western Pacific (WP) region are among the highest in the world. Verifying Insulin Strategy and Initial Health Outcome Analysis (VISION) was an 18 month observational study that explored treatment approaches in patients with type 2 diabetes mellitus (T2DM) initiating insulin in the WP region. METHODS A total of 1065 patients aged ≥18 years with T2DM initiating insulin therapy in normal clinical course were enrolled from Hong Kong, Malaysia, Philippines, Taiwan and Thailand. Participants' data was recorded by the treating physicians. Patient-reported outcomes (PROs) were assessed using questionnaires completed by participants. RESULTS The mean age of patients was 57.2 years with mean glycosylated hemoglobin (HbA1c) of 10.0%. About 66% of patients had an HbA1c ≥9.0% at insulin initiation despite 74% of them being on two or more oral antidiabetic agents at the time of insulin initiation. Basal insulin was initiated in 72% and premixed insulin in 27% of patients. Changes in insulin therapy was observed in 63% of patients and, by the end of study, 28% achieved HbA1c levels of <7.5%. The proportion of patients completely satisfied with their insulin treatment increased over the study course and the quality of life (QoL) score increased from baseline to the study end. CONCLUSION As high HbA1C levels indicate a delayed start of insulin therapy, timely initiation and early intensification of insulin therapy is necessary in the region to achieve adequate glycemic control in time and prevent diabetes complications. Data from PROs suggests that the insulin treatment improves QoL in most patients.
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Affiliation(s)
| | | | - Risa Ozaki
- c The Chinese University of Hong Kong , Hong Kong , China
| | | | | | | | - Rong Qi
- g Eli Lilly and Company , Indianapolis , IN , USA
| | - Wayne H-H Sheu
- h Division of Endocrinology and Metabolism, Department of Internal Medicine , Taichung Veterans General Hospital , Taichung , Taiwan
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Sowa NA, Jeng P, Bauer AM, Cerimele JM, Unützer J, Bao Y, Chwastiak L. Psychiatric Case Review and Treatment Intensification in Collaborative Care Management for Depression in Primary Care. Psychiatr Serv 2018; 69:549-554. [PMID: 29385955 PMCID: PMC6063310 DOI: 10.1176/appi.ps.201700243] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined whether psychiatric case review was associated with depression medication modification in a large implementation program of collaborative care for depression in safety-net primary care clinics. METHODS Registry data were examined from an implementation of the collaborative care model in Washington State. A total of 14,960 adults from 178 primary care clinics who initiated care between January 1, 2008, and September 30, 2014, and who had a baseline Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher were included. Rates of psychiatric case reviews and receipt of new depression medications were extracted from the registry for all patients and for a subset of patients who did not improve by eight weeks of treatment (did not achieve a PHQ-9 score of less than 10 or a reduction in PHQ-9 score of 50% or more, compared with baseline). RESULTS One-half of patients received a new depression medication. Psychiatric case review in any given month was associated with a doubling of the probability of receiving a new medication in the following month. Among patients who did not improve by eight weeks of treatment, a psychiatric case review during weeks 8-12 was associated with a higher rate of receipt of new medications during weeks 8-16 or weeks 8-20. CONCLUSIONS In a collaborative care program, psychiatric case review was associated with higher rates of subsequent receipt of a new depression medication. This finding supports the importance of psychiatric case review in reducing clinical inertia in collaborative care treatment of depression.
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Affiliation(s)
- Nathaniel A Sowa
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Philip Jeng
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Amy M Bauer
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Joseph M Cerimele
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Jürgen Unützer
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Yuhua Bao
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
| | - Lydia Chwastiak
- Dr. Sowa, Dr. Bauer, Dr. Cerimele, Dr. Unützer, and Dr. Chwastiak are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Mr. Jeng and Dr. Bao are with the Department of Healthcare Policy and Research, Cornell University Joan and Sanford I. Weill Medical College, New York
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Barton AB, Okorodudu DE, Bosworth HB, Crowley MJ. Clinical Inertia in a Randomized Trial of Telemedicine-Based Chronic Disease Management: Lessons Learned. Telemed J E Health 2018; 24:742-748. [PMID: 29341850 DOI: 10.1089/tmj.2017.0184] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Treatment nonadherence and clinical inertia perpetuate poor cardiovascular disease (CVD) risk factor control. Telemedicine interventions may counter both treatment nonadherence and clinical inertia. INTRODUCTION We explored why a telemedicine intervention designed to reduce treatment nonadherence and clinical inertia did not improve CVD risk factor control, despite enhancing treatment adherence versus usual care. METHODS In this analysis of a randomized trial, we studied recipients of the 12-month telemedicine intervention. This intervention comprised two nurse-administered components: (1) monthly self-management education targeting improved treatment adherence; and (2) quarterly medication management facilitation designed to support treatment intensification by primary care (thereby reducing clinical inertia). For each medication management facilitation encounter, we ascertained whether patients met treatment goals, and if not, whether primary care recommended treatment intensification following the encounter. We assessed disease control associated with encounters, where intensification was/was not recommended. RESULTS We examined 455 encounters across 182 intervention recipients (100% African Americans with type 2 diabetes). Even after accounting for valid reasons for deferring intensification (e.g., treatment nonadherence), intensification was not recommended in 67.5% of encounters in which hemoglobin A1c was above goal, 72.5% in which systolic blood pressure was above goal, and 73.9% in which low-density lipoprotein cholesterol was above goal. In each disease state, treatment intensification was more likely with poorer control. CONCLUSIONS Despite enhancing treatment adherence, this intervention was unsuccessful in countering clinical inertia, likely explaining its lack of effect on CVD risk factors. We identify several lessons learned that may benefit investigators and healthcare systems.
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Affiliation(s)
- Anna Beth Barton
- 1 Richmond Diabetes and Endocrinology, Bon Secours Medical Group , Richmond, Virginia
| | - Daniel E Okorodudu
- 2 Endocrinology Service, Guadalupe Regional Medical Center , Seguin, Texas
| | - Hayden B Bosworth
- 3 Center for Health Services Research in Primary Care , Durham VAMC, Durham, North Carolina.,4 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina
| | - Matthew J Crowley
- 3 Center for Health Services Research in Primary Care , Durham VAMC, Durham, North Carolina.,5 Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Duke University , Durham, North Carolina
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Abstract
INTRODUCTION Forgetting shapes learning in two different ways. It impedes learning when important lessons are forgotten. Equally, it can be difficult to enact new lessons if we do not let go of old beliefs and practices that are no longer useful. A learning health system (LHS) that wishes to improve health service delivery will need to find ways to remember processes that shape quality and safety - using data that often resides beyond electronic health records. An LHS will also need to "forget", or programmatically decommission, obsolete practices, whose persistence otherwise leads to unnecessary system complexity and inertia to change. DISCUSSION New forms of data needed to improve health services include process metrics extracted from digital systems; human-level metrics that capture workflow patterns and clinician behaviors; and multivariate process patterns that can identify service "syndromes." To avoid inertia to change, system complexity must be reduced by retiring (or forgetting) inefficient or unhelpful work practices. Biological models of programmed cell death provide a rich set of mechanisms to decommission elements of health services. These models suggest health service elements should be able to detect the end of their useful life and should contain internal mechanisms to orchestrate decommissioning-in contrast to current service decommissioning, which is an externally initiated, top-down down-driven process. CONCLUSIONS An LHS should take advantage of digital infrastructure to bring together people, sensors, analytics, and quasi-autonomous mechanisms for service adaptation. By drawing inspiration from biology, we can design LHSs that do not just remember but also actively forget.
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Affiliation(s)
- Enrico Coiera
- Centre for Health Informatics, Australian Institute of Health InnovationMacquarie UniversitySydneyAustralia
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Mahabaleshwarkar R, Gohs F, Mulder H, Wilkins N, DeSantis A, Anderson WE, Ejzykowicz F, Rajpathak S, Norton HJ. Patient and Provider Factors Affecting Clinical Inertia in Patients With Type 2 Diabetes on Metformin Monotherapy. Clin Ther 2017; 39:1658-1670.e6. [PMID: 28689692 DOI: 10.1016/j.clinthera.2017.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Our aim was to determine the extent of clinical inertia and the associated patient and provider factors in patients with type 2 diabetes on metformin monotherapy (MM) at a large integrated health care system in the United States. METHODS The study cohort included patients with type 2 diabetes aged 18 to 85 years, on MM between January 2009 and September 2013, who experienced MM failure (had an uncontrolled glycosylated hemoglobin [HbA1c] reading (≥8.0% [64 mmol/mol]) after at least 90 days of MM). Clinical inertia was defined as absence of treatment intensification with an add-on therapy within 180 days after the MM failure (index date). The impact of patient and provider factors on clinical inertia was determined using generalized estimating equations. FINDINGS The study cohort consisted of 996 patients; 58% were men and 59% were white, with a mean age of 53 (11.8) years. Of these, 49.8% experienced clinical inertia. Lower HbA1c at index date, absence of liver diseases, absence of renal diseases, and greater provider age were associated with clinical inertia. The clinical inertia rate in a secondary analysis considering HbA1c <7.0% (53 mmol/mol) as glycemic control was 67.9%. Greater patient age, lower HbA1c at index date, greater provider age, and being a primary care physician were associated with clinical inertia. IMPLICATIONS Considerable clinical inertia rates were observed in our real-world patient population, suggesting the need of interventions to reduce clinical inertia in clinical practice. Information about patient and provider factors affecting clinical inertia provided by this study could help healthcare policymakers plan and implement such interventions.
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Abstract
BACKGROUND Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature. METHODS An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online. RESULTS Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed. CONCLUSION Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section.
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Affiliation(s)
- Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA
- Lawrence Blonde, Department of Endocrinology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Pablo Aschner
- Endocrinology Unit, Javeriana University School of Medicine, Bogotá, Colombia
| | - Clifford Bailey
- School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Linong Ji
- Peking University People’s Hospital, Beijing, China
| | - Lawrence A Leiter
- Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Division of Endocrinology & Metabolism, University of Toronto, Toronto, ON, Canada
| | - Stephan Matthaei
- Diabetes, Metabolism and Endocrinology Center, Quakenbrück Hospital, Quakenbrück, Germany
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Fairchild PC, Nathan AG, Quinn M, Huang ES, Laiteerapong N. Patients' Future Expectations for Diabetes and Hypertension Treatments: "Through the Diet… I Think This is Going to Go Away.". J Gen Intern Med 2017; 32:49-55. [PMID: 27730483 PMCID: PMC5215165 DOI: 10.1007/s11606-016-3871-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/17/2016] [Accepted: 09/15/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diabetes and hypertension are chronic conditions for which over 90 % of patients require medication regimens that must be intensified over time. However, delays in intensification are common, and may be partially due to unrealistic patient expectations. OBJECTIVE To explore whether patient expectations regarding their diabetes and hypertension are congruent with the natural history of these conditions. DESIGN Qualitative analysis of semi-structured interviews. PARTICIPANTS Sixty adults from an urban academic primary care clinic taking oral medications for both diabetes (duration <10 years) and hypertension (any duration) MAIN MEASURES: (1) Expectations for their a) current diabetes and hypertension medications, b) need for additional medications, c) likelihood of cure (not requiring medications); (2) preferences for receiving information on expected duration of treatments KEY RESULTS: The average patient age was 60 years, and 65 % were women. Nearly half (48 %) of participants expected to discontinue current diabetes medications in 6 years or less, whereas only one-fifth (22 %) expected to take medications for life. For blood pressure medications, one-third (37 %) expected to stop medicines in 6 years or less, and one-third expected to take medicines for life. The vast majority did not expect that they would need additional medications in the future (oral diabetes medications: 85 %; insulin: 87 %; hypertension medications: 93 %). A majority expected that their diabetes (65 %) and hypertension (58 %) would be cured. Most participants believed that intensifying lifestyle changes would allow them to discontinue medications, avoid additional medications, or cure their diabetes and hypertension. Nearly all participants (97 %) wanted to hear information on the expected duration of their diabetes and hypertension treatments from their healthcare provider. CONCLUSIONS Providers should educate patients on the natural history of diabetes and hypertension in order to manage patient expectations for current and future medications. Future research should assess whether education can increase the adoption of and adherence to medications, without diminishing enthusiasm for lifestyle changes.
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Affiliation(s)
- Paige C Fairchild
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aviva G Nathan
- Department of Medicine, Section of General Internal Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Michael Quinn
- Department of Medicine, Section of General Internal Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Elbert S Huang
- Department of Medicine, Section of General Internal Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA
| | - Neda Laiteerapong
- Department of Medicine, Section of General Internal Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
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29
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Kronish IM, Moise N, McGinn T, Quan Y, Chaplin W, Gallagher BD, Davidson KW. An Electronic Adherence Measurement Intervention to Reduce Clinical Inertia in the Treatment of Uncontrolled Hypertension: The MATCH Cluster Randomized Clinical Trial. J Gen Intern Med 2016; 31:1294-1300. [PMID: 27255750 PMCID: PMC5071278 DOI: 10.1007/s11606-016-3757-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/09/2016] [Accepted: 05/10/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND To appropriately manage uncontrolled hypertension, clinicians must decide whether blood pressure (BP) is above goal due to a need for additional medication or to medication nonadherence. Yet, clinicians are poor judges of adherence, and uncertainty about adherence may promote inertia with respect to medication modification. OBJECTIVE We aimed to determine the effect of sharing electronically-measured adherence data with clinicians on the management of uncontrolled hypertension. DESIGN This was a cluster randomized trial. PARTICIPANTS Twenty-four primary care providers (12 intervention, 12 usual care; cluster units) and 100 patients with uncontrolled hypertension (65 intervention, 35 usual care) were included in the study. INTERVENTIONS At one visit per patient, clinicians in the intervention group received a report summarizing electronically measured adherence to the BP regimen and recommended clinical actions. Clinicians in the control group did not receive a report. MAIN MEASURES The primary outcome was the proportion of visits with appropriate clinical management (i.e., treatment intensification among adherent patients and adherence counseling among nonadherent patients). Secondary outcomes included patient-rated quality of care and communication during the visit. KEY RESULTS The proportion of visits with appropriate clinical management was higher in the intervention group than the control group (45 out of 65; 69 %) versus (12 out of 35; 34 %; p = 0.001). A higher proportion of adherent patients in the intervention group had their regimen intensified (p = 0.01), and a higher proportion of nonadherent patients in the intervention group received adherence counseling (p = 0.005). Patients in the intervention group were more likely to give their clinician high ratings on quality of care (p = 0.05), and on measures of patient-centered (p = 0.001) and collaborative communication (p = 0.02). CONCLUSIONS Providing clinicians with electronically-measured antihypertensive adherence reports reduces inertia in the management of uncontrolled hypertension. TRIAL REGISTRATION NCT01257347 ; http://clinicaltrials.gov/show/ NCT01257347.
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Affiliation(s)
- Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA.
| | - Nathalie Moise
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Yan Quan
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
| | - William Chaplin
- Department of Psychology, St. John's University, Jamaica, NY, USA
| | - Benjamin D Gallagher
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
| | - Karina W Davidson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
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Abstract
Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.
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Affiliation(s)
- Kim L Lavoie
- Department of Psychology, University of Quebec at Montreal (UQAM), Montreal, Quebec H3C 3P8, Canada.,Montreal Behavioural Medicine Centre (MBMC), Research Centre, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec H2J 1C5, Canada
| | - Joshua A Rash
- Department of Psychology, University of Calgary, Calgary, Alberta T2N 1N4, Canada;
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, Calgary, Alberta T2N 1N4, Canada;
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Fontil V, Bibbins-Domingo K, Nguyen OK, Guzman D, Goldman LE. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians' Offices. Health Serv Res 2016; 52:807-825. [PMID: 27283354 DOI: 10.1111/1475-6773.12516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine adherence to guideline-concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices. DATA SOURCES/STUDY SETTING National Ambulatory Medical Care Survey from 2006 to 2010. STUDY DESIGN We examined four guideline-concordant treatment practices: initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHC with private physicians' offices overall and by payer group. DATA COLLECTION/EXTRACTION METHODS We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices. PRINCIPAL FINDINGS Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 percent CI: 0.6-1.9), whereas Medicaid patients at private physicians' offices were less likely to receive a new medication (AOR 0.3, 95 percent CI: 0.1-0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95 percent CI: 0.4-0.9). Thiazide use for patients was similar in both settings (AOR 0.8, 95 percent CI: 0.4-1.7). Use of aldosterone antagonists was too rare (2.1 percent at CHCs and 1.5 percent at private clinics) to allow for statistically reliable comparisons. CONCLUSIONS Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.
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Affiliation(s)
- Valy Fontil
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA
| | - Kirsten Bibbins-Domingo
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Oanh Kieu Nguyen
- Divisions of General Internal Medicine and Outcomes and Health Services Research, UT Southwestern, Dallas, TX
| | - David Guzman
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Lauren Elizabeth Goldman
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
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Abstract
According to the concept developed by Thomas Kuhn, a scientific revolution occurs when scientists encounter a crisis due to the observation of anomalies that cannot be explained by the generally accepted paradigm within which scientific progress has thereto been made: a scientific revolution can therefore be described as a change in paradigm aimed at solving a crisis. Described herein is an application of this concept to the medical realm, starting from the reflection that during the past decades, the medical community has encountered two anomalies that, by their frequency and consequences, represent a crisis in the system, as they deeply jeopardize the efficiency of care: nonadherence of patients who do not follow the prescriptions of their doctors, and clinical inertia of doctors who do not comply with good practice guidelines. It is proposed that these phenomena are caused by a contrast between, on the one hand, the complex thought of patients and doctors that sometimes escapes rationalization, and on the other hand, the simplification imposed by the current paradigm of medicine dominated by the technical rationality of evidence-based medicine. It is suggested therefore that this crisis must provoke a change in paradigm, inventing a new model of care defined by an ability to take again into account, on an individual basis, the complex thought of patients and doctors. If this overall analysis is correct, such a person-centered care model should represent a solution to the two problems of patients' nonadherence and doctors' clinical inertia, as it tackles their cause. These considerations may have important implications for the teaching and the practice of medicine.
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Affiliation(s)
- Gérard Reach
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital AP-HP, Sorbonne Paris Cité, Bobigny, France
- EA 3412, Centre de Recherche en Nutrition Humaine Ile-de-France (CRNH-IDF), Paris 13 University, Sorbonne Paris Cité, Bobigny, France
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Abstract
OBJECTIVES Gout is a chronic, extremely painful disease that is potentially curable when treated effectively. Unfortunately approximately one-half of patients with gout are inadequately controlled. METHODS We surveyed 315 primary care physicians in the United States and Europe to investigate current practice in the real world, as distinct from recommendations in guidelines. RESULTS Our survey on 1657 patients found that regular testing of serum uric acid, in conformity with the guidelines, was conducted by approximately 50% of physicians. Advice to patients on diet and lifestyle was less well implemented, and identification of overweight/obese patients was inconsistent. CONCLUSION Improvements in practice by physicians would include comprehensive assessment of the patient, adoption of regular monitoring during treatment, and the provision of patient education on adherence and lifestyle.
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Affiliation(s)
- Paul P Doghramji
- a Collegeville Family Practice , Ursinus College , Collegeville , PA , USA
| | | | - Robert Wood
- c Health Economics and Statistics , Adelphi Real World , Cheshire , UK
| | - Robert Morlock
- d Health Economics and Outcomes Research , Ardea Biosciences, Inc ., San Diego , CA , USA
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Crowley MJ, Holleman R, Klamerus ML, Bosworth HB, Edelman D, Heisler M. Factors associated with persistent poorly controlled diabetes mellitus: clues to improving management in patients with resistant poor control. Chronic Illn 2014; 10:291-302. [PMID: 24567193 PMCID: PMC4317345 DOI: 10.1177/1742395314523653] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Patients with persistent poorly controlled diabetes mellitus (PPDM), defined as an uninterrupted hemoglobin A1c >8.0% for ≥1 year despite standard care, are at high risk for complications. Additional research to define patient factors associated with PPDM could suggest barriers to improvement in this group and inform the development of targeted strategies to address these patients' resistant diabetes. METHODS We analyzed patients with type 2 diabetes from a multi-site randomized trial. We characterized patients with PPDM relative to other patients using detailed survey data and multivariable modeling. RESULTS Of 963 patients, 118 (12%) had PPDM, 265 (28%) were intermittently poorly controlled, and 580 (60%) were well-controlled. Patients with PPDM had younger age, earlier diabetes diagnosis, insulin use, higher antihypertensive burden, higher low-density lipoprotein cholesterol, and lower statin use relative to well-controlled patients. Among patients with objective adherence data (Veterans Affairs patients), a larger oral diabetes medication refill gap was associated with PPDM. DISCUSSION Strategies are needed to target-specific barriers to improvement among patients whose diabetes is resistant to standard diabetes care. Our data suggest that strategies for targeting PPDM should accommodate younger patients' lifestyles, include medication management for insulin titration and comorbid disease conditions, and address barriers to self-management adherence.
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Affiliation(s)
- Matthew J Crowley
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Rob Holleman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Mandi L Klamerus
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - David Edelman
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Michele Heisler
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Kamenov Z. Effectiveness and Tolerability of Second-Line Therapy with Vildagliptin Versus Other Oral Agents in Type 2 Diabetes (EDGE): Post Hoc Sub-Analysis of Bulgarian Data. Diabetes Ther 2014; 5:483-98. [PMID: 25245616 PMCID: PMC4269645 DOI: 10.1007/s13300-014-0083-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Metformin is an established first-line treatment for type 2 diabetes mellitus (T2DM) patients but intensification of oral anti-diabetic therapy is usually required over time. The effectiveness of diabetes control with vildaGliptin and vildagliptin/mEtformin (EDGE) study compared effectiveness and safety of vildagliptin and other oral anti-diabetic drugs (OAD) in 45,868 patients worldwide with inadequately controlled T2DM by monotherapy under real-life conditions. Here, we present effectiveness results for patients receiving vildagliptin (vildagliptin cohort) or another OAD (comparator cohort) add-on to monotherapy in Bulgaria. METHODS The eligible diabetes patients inadequately controlled with current monotherapy were assigned to add-on treatment, which was chosen by the physician based on patient's need. Effectiveness was assessed by glycated hemoglobin (HbA1c) drop and by means of a composite endpoint assessing the proportion of patients responding to treatment (HbA1c <7%) without proven hypoglycemic event and significant weight gain (>5%) after 12 months of treatment. RESULTS In total, 754 patients were enrolled in Bulgaria, 384 in the vildagliptin cohort and 369 in the comparator cohort. Mean HbA1c change from baseline was significantly higher with vildagliptin compared to the comparator (-1.35% in the vildagliptin cohort and -0.55% in the comparator cohort, P < 0.001). In the vildagliptin cohort, a higher proportion of patients reached the composite endpoint (HbA1c <7%, no hypoglycemic events, no weight gain) when compared to the comparator cohort (vildagliptin: 32.3%; comparator: 8.4%; P < 0.001). Overall, vildagliptin was well tolerated with similarly low incidences of total adverse events (3.4% versus 1.9% in the comparator group) and serious adverse events (2.3% versus 1.1% in the comparator group). CONCLUSIONS In real-life clinical practice in Bulgaria, vildagliptin is associated with a greater HbA1c drop, and a higher proportion of patients reaching target HbA1c without hypoglycemia and weight gain compared to comparator.
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Affiliation(s)
- Zdravko Kamenov
- Clinic of Endocrinology, University Hospital "Alexandrovska", Medical University-Sofia, St. Georgi Sofiiski 1, 1431, Sofia, Bulgaria,
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Aujoulat I, Jacquemin P, Rietzschel E, Scheen A, Tréfois P, Wens J, Darras E, Hermans MP. Factors associated with clinical inertia: an integrative review. Adv Med Educ Pract 2014; 5:141-7. [PMID: 24868181 PMCID: PMC4028485 DOI: 10.2147/amep.s59022] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Failure to initiate or intensify therapy according to evidence-based guidelines is increasingly being acknowledged as a phenomenon that contributes to inadequate management of chronic conditions, and is referred to as clinical inertia. However, the number and complexity of factors associated with the clinical reasoning that underlies the decision-making processes in medicine calls for a critical examination of the consistency of the concept. Indeed, in the absence of information on and justification of treatment decisions that were made, clinical inertia may be only apparent, and actually reflect good clinical practice. This integrative review seeks to address the factors generally associated with clinical inaction, in order to better delineate the concept of true clinical inertia.
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Affiliation(s)
- Isabelle Aujoulat
- Université Catholique de Louvain, Institute of Health and Society, Brussels
| | - Patricia Jacquemin
- Université Catholique de Louvain, Institute of Health and Society, Brussels
| | - Ernst Rietzschel
- Ghent University, Department of Cardiovascular Diseases and Department of Public Health, Faculty of Medicine and Health Sciences, Ghent
| | - André Scheen
- University of Liège, Division of Diabetes, Nutrition and Metabolic Disorders and Clinical Pharmacology Unit, CHU Liège, Liège
| | | | - Johan Wens
- University of Antwerp, Faculty of Medicine and Health Sciences, Primary and Interdisciplinary Care Antwerp
| | - Elisabeth Darras
- Université Catholique de Louvain, Institute of Health and Society, Brussels
| | - Michel P Hermans
- Université Catholique de Louvain, Institute of Experimental and Clinical Research and Cliniques Universitaires Saint-Luc, Department of Endocrinology and Nutrition, Brussels, Belgium
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Affiliation(s)
- Nathalie Moise
- Center for Behavioral and Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, New York
| | - Karina W Davidson
- Center for Behavioral and Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, New York2Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - William Chaplin
- Center for Behavioral and Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, New York3Department of Psychology, St John's University, Queens, New York
| | - Steven Shea
- Center for Behavioral and Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, New York4Department of Epidemiology, Joseph Mailman School of Public Health, Columbia University, New York, New York
| | - Ian Kronish
- Center for Behavioral and Cardiovascular Health, Division of General Medicine, Columbia University Medical Center, New York, New York
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Abstract
BACKGROUND Studies assessing attitudes and beliefs of physicians regarding insulin therapy in Arab countries are scant despite the high prevalence of type 2 diabetes mellitus (T2DM). OBJECTIVE This study examines family physicians' attitudes and beliefs towards insulin therapy in T2DM patients in the East Mediterranean Region of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. METHODS This is a cross-sectional study conducted on 348 family physicians invited via email to fill an anonymous online questionnaire about their attitudes, beliefs and perceived barriers regarding insulin initiation in T2DM patients. RESULTS One hundred and twenty-two physicians completed the questionnaire. Of the 122 physicians, 73.6% preferred to delay insulin initiation until it is absolutely essential and 59.0% initiated it themselves. The majority agreed that T2DM patients benefit from insulin prior to the development of complications (85.7%) and that patient education is important (99.1%) and uncomplicated (74.7%). Sixty-three per cent expressed reluctance to start insulin mostly because of perceived patients' reluctance. Referral to endocrinologists to initiate insulin therapy was associated with inadequate experience and concern about risks, particularly in elderly patients (backward logistic regression, P < 0.05). Physicians' reluctance to initiate insulin therapy was associated with patients' perception of insulin initiation as a personal failure and threat to the quality of life (backward logistic regression, P < 0.05). CONCLUSIONS Although family physicians in the Arab world believe in the benefits of insulin therapy, many are reluctant to initiate it themselves. Further studies are needed per country, as well as multiple measures to minimize the physicians' barriers to insulin prescription.
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Affiliation(s)
- Najla A Lakkis
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
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Coan KE, Schlinkert AB, Beck BR, Haakinson DJ, Castro JC, Apsey HA, Schlinkert, RT, Cook CB. Clinical inertia during postoperative management of diabetes mellitus: relationship between hyperglycemia and insulin therapy intensification. J Diabetes Sci Technol 2013; 7:880-7. [PMID: 23911169 PMCID: PMC3879752 DOI: 10.1177/193229681300700410] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our objective was to assess the application of insulin regimens in surgical postoperative patients with diabetes. METHODS A chart review was conducted of patients with diabetes who were hospitalized postoperatively between January 1 and April 30, 2011. Analysis was restricted to patients hospitalized for ≥3 days and excluded cases with an endocrinology consult. Insulin regimens were categorized as "basal plus short acting," "short acting only," or "none," and the pattern of use was evaluated by hyperglycemia severity according to tertiles of both mean glucose and the number of glucose measurements >180 mg/dl. RESULTS Among cases selected for analysis (n = 119), examination of changes in insulin use based on tertiles of mean glucose showed that use of basal plus short-acting insulin increased from 10% in the lowest tertile (mean glucose, 120 mg/dl) to 18% in the highest tertile (mean glucose, 198 mg/dl; p < .01); however, 70% of patients in the highest tertile continued to receive short-acting insulin only, with 12% receiving no insulin. Intensification of insulin to a basal plus short-acting regimen was also seen when changes were evaluated by the number of measurements >180 mg/dl (p < .01), but 70% and 12% of patients in the highest tertile still remained only on short-acting insulin or received no insulin, respectively. CONCLUSIONS Use of basal plus short-acting insulin therapy increased with worsening hyperglycemia, but many cases did not have therapy intensified to the recommended insulin regimen--evidence of clinical inertia. Strategies should be devised to overcome inpatient clinical inertia in the treatment of postoperative patients with diabetes.
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Harris SB, Gerstein HC, Yale JF, Berard L, Stewart J, Webster-Bogaert S, Tompkins JW. Can community retail pharmacist and diabetes expert support facilitate insulin initiation by family physicians? Results of the AIM@GP randomized controlled trial. BMC Health Serv Res 2013; 13:71. [PMID: 23433347 PMCID: PMC3585701 DOI: 10.1186/1472-6963-13-71] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 02/11/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Limited evidence exists on the effectiveness of external diabetes support provided by diabetes specialists and community retail pharmacists to facilitate insulin-prescribing in family practice. METHODS A stratified, parallel group, randomized control study was conducted in 15 sites across Canada. Family physicians received insulin initiation/titration education, a physician-specific 'report card' on the characteristics of their type 2 diabetes (T2DM) population, and a registry of insulin-eligible patients at a workshop. Intervention physicians in addition received: (1) diabetes specialist/educator consultation support (active diabetes specialist/educator consultation support for 2 months [the educator initiated contact every 2 weeks] and passive consultation support for 10 months [family physician initiated as needed]); and (2) community retail pharmacist support (option to refer patients to the pharmacist(s) for a 1-hour insulin-initiation session). The primary outcome was the insulin prescribing rate (IPR) per physician defined as the number of insulin starts of insulin-eligible patients during the 12-month strategy. RESULTS Consenting, eligible physicians (n = 151) participated with 15 specialist sites and 107 community pharmacists providing the intervention. Most physicians were male (74%), and had an average of 81 patients with T2DM. Few (9%) routinely initiated patients on insulin. Physicians were randomly allocated to usual care (n = 78) or the intervention (n = 73). Intervention physicians had a mean (SE) IPR of 2.28 (0.27) compared to 2.29 (0.25) for control physicians, with an estimated adjusted RR (95% CI) of 0.99 (0.80 to 1.24), p = 0.96. CONCLUSIONS An insulin support program utilizing diabetes experts and community retail pharmacists to enhance insulin prescribing in family practice was not successful. Too few physicians are appropriately intensifying diabetes management through insulin initiation, and aggressive therapeutic treatment is lacking.
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Affiliation(s)
- Stewart B Harris
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, 245-100 Collip Circle, London, Ontario, N6G 4X8, Canada
| | - Hertzel C Gerstein
- Department of Medicine, McMaster University, Health Sciences Centre Room 3 V38, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Jean-François Yale
- Department of Medicine, McGill University, Royal Victoria Hospital, 687 Pine Avenue West, M9.05, Montreal, Quebec, H3A 1A1, Canada
| | - Lori Berard
- Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Manitoba, R3A 1R9, Canada
| | - John Stewart
- sanofi-aventis, 2150 St. Elzear Blvd. West, Laval, Quebec, H7L 4A8, Canada
| | - Susan Webster-Bogaert
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, 245-100 Collip Circle, London, Ontario, N6G 4X8, Canada
| | - Jordan W Tompkins
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, The University of Western Ontario, 245-100 Collip Circle, London, Ontario, N6G 4X8, Canada
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Reach G, Le Pautremat V, Gupta S. Determinants and consequences of insulin initiation for type 2 diabetes in France: analysis of the National Health and Wellness Survey. Patient Prefer Adherence 2013; 7:1007-23. [PMID: 24143079 PMCID: PMC3797252 DOI: 10.2147/ppa.s51299] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The aim of the study was to identify the intrinsic patient characteristics and extrinsic environmental factors predicting prescription and use and, more specifically, early initiation (up to 5 years of disease duration) of insulin for type 2 diabetes in France. A secondary objective was to evaluate the impact of insulin therapy on mental and physical quality of life and patient adherence. METHODS The data used in this study were derived from the 2008, 2010, and 2011 France National Health and Wellness Survey. This survey is an annual, cross-sectional, self-administered, Internet-based questionnaire among a nationwide representative sample of adults (aged 18 years or older). Of the total of 45,958 persons recruited in France, 1,933 respondents (deduped) were identified as diagnosed with type 2 diabetes. All unique respondents from the three waves, currently using insulin or oral bitherapy or tritherapy at the time of assessment, were included in this analysis. RESULTS Early (versus late) initiation of insulin therapy was 9.9 times more likely to be prescribed by an endocrinologist or diabetologist than by a primary care physician (P < 0.0001). Younger age at diagnosis and current smoking habits were significant predictors of early (versus late) insulin initiation (odds ratio [OR] 1.031, 95% confidence interval [CI] 1.005-1.059, P = 0.0196, and OR 2.537, 95% CI 1.165-5.524, P = 0.0191, respectively). Patients with a yearly income ≥€50,000 were less likely to be put on insulin early (P = 0.0399). A link between insulin prescription and complications was shown only in univariate analysis. Mental quality of life was lower in patients on early (versus late) insulin, but only in patients with diabetes-related complications. Insulin users (versus oral bitherapy or tritherapy users) had 3.0 times greater odds of being adherent than uncontrolled oral bitherapy or tritherapy users (OR 2.983, 95% CI 1.37-6.495, P = 0.0059). CONCLUSION This study confirms the role of specialists in early initiation of insulin, and the data presented herein reflect the fact that early initiation is more frequent in younger patients, patients with diabetes-related complications, and current smokers, and less frequent in patients with a higher income. Moreover, we observed that being treated with insulin was not associated with deterioration in quality of life, and insulin-treated patients were more often adherent than uncontrolled oral bitherapy or tritherapy users. These data suggest that doctors' concerns about patient adherence and detrimental effects on quality of life should not be a barrier to their decision regarding early initiation of insulin therapy. Due to the nature of this cross-sectional survey (eg, inability to assess treatment flow), further research is needed to confirm its findings.
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Affiliation(s)
- Gérard Reach
- Department of Endocrinology, Diabetes, and Metabolic Diseases, Avicenne Hospital APHP, and EA 3412, CRNH-IdF, Paris 13 University, Sorbonnne Paris Cité, Bobigny, France
- Correspondence: Gérard Reach Service d’Endocrinologie, Diabétologie, Maladies Métaboliques, Hôpital Avicenne APHP, 125 route de Stalingrad, 93000 Bobigny, France, Tel +331 4895 5158, Fax +331 4895 5560, Email
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Marrett E, Zhang Q, Kanitscheider C, Davies MJ, Radican L, Feinglos MN. Physician reasons for nonpharmacologic treatment of hyperglycemia in older patients newly diagnosed with type 2 diabetes mellitus. Diabetes Ther 2012; 3:5. [PMID: 22700283 PMCID: PMC3508110 DOI: 10.1007/s13300-012-0005-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION To identify reasons why primary care physicians (PCPs) do not treat older patients newly diagnosed with type 2 diabetes mellitus (T2DM) with antihyperglycemic agents following diagnosis. METHODS US PCPs were surveyed via the internet regarding their reasons for not treating patients aged >65 years diagnosed with T2DM and had not yet initiated antihyperglycemic therapy for ≥6 months after diagnosis. PCPs were requested to provide relevant clinical information for untreated older patients and select applicable reasons for not initiating treatment from a list of 35 possibilities, grouped into five categories. RESULTS A total of 508 PCPs completed the online survey and provided complete clinical data for 770 patients. The reasons provided by the first-ranked physician for not initiating antihyperglycemic therapy were related to diet and exercise (57.5%); mild hyperglycemia (23.8%); patient's concerns (13.4%); concerns about antihyperglycemic agents (3.0%); and comorbidities and polypharmacy (2.3%). The "diet and exercise" category was the most common first-ranked non-treatment reason, regardless of recent hemoglobin A(1c) (HbA(1c)) stratum. Reasons within the "patient's concerns," "concerns related to antihyperglycemic agents," and "comorbidities and polypharmacy" categories tended to be selected more often as first-ranked reasons by physicians for patients with higher HbA(1c) values. Of the 158 patients whose physicians planned to initiate antihyperglycemic therapy within the next month, 54.4% already had a most recent HbA(1c) value above their physician-stated threshold for treatment initiation. CONCLUSION In the PCPs studied, there was a tendency to select appropriate reasons for non-treatment with antihyperglycemic agents given their patients' glycemic status. However, there was inertia related to the initiation of pharmacological therapy in some older patients with newly diagnosed T2DM. Important factors included physicians' perceptions of "mild" hyperglycemia and the HbA(1c) threshold for using antihyperglycemic agents.
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Affiliation(s)
- Elizabeth Marrett
- Global Health Outcomes, WS2E85, 1 Merck Drive, Whitehouse Station, NJ, 08889, USA,
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Sinclair AJ, Alexander CM, Davies MJ, Zhao C, Mavros P. Factors associated with initiation of antihyperglycaemic medication in UK patients with newly diagnosed type 2 diabetes. BMC Endocr Disord 2012; 12:1. [PMID: 22397700 PMCID: PMC3353844 DOI: 10.1186/1472-6823-12-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 03/07/2012] [Indexed: 11/10/2022] Open
Abstract
AIM To assess the factors associated with antihyperglycaemic medication initiation in UK patients with newly diagnosed type 2 diabetes. METHODS In a retrospective cohort study, patients with newly diagnosed type 2 diabetes were identified during the index period of 2003-2005. Eligible patients were ≥ 30 years old at the date of the first observed diabetes diagnosis (referred to as index date) and had at least 2 years of follow-up medical history (N = 9,158). Initiation of antihyperglycaemic medication (i.e., treatment) was assessed in the 2-year period following the index date. Adjusted Cox regression models were used to examine the association between time to medication initiation and patient age and other factors. RESULTS Mean (SD) HbA1c at diagnosis was 8.1% (2.3). Overall, 51% of patients initiated antihyperglycaemic medication within 2 years (65%, 55%, 46% and 40% for patients in the 30- < 45, 45- < 65, 65- < 75, 75+ age groups, respectively). Among the treated patients, median (25th, 75th percentile) time to treatment initiation was 63 (8, 257) days. Of the patients with HbA1c ≥ 7.5% at diagnosis, 87% initiated treatment within 2 years. These patients with a higher HbA1c also had shorter time to treatment initiation (adjusted hazard ratio (HR) = 2.44 [95% confidence interval (CI): 1.61, 3.70]; p < 0.0001). Increasing age (in years) was negatively associated with time to treatment initiation (HR = 0.98 [95% CI: 0.97, 0.99]; p < 0.001). Factors significantly associated with shorter time to treatment initiation included female gender and use of cardiovascular medications at baseline or initiated during follow up. CONCLUSIONS In this UK cohort of patients with newly diagnosed type 2 diabetes, only 51% had antihyperglycaemic medication initiated over a 2-year period following diagnosis. Older patients were significantly less likely to have been prescribed antihyperglycaemic medications. Elevated HbA1c was the strongest factor associated with initiating antihyperglycaemic medication in these patients.
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Affiliation(s)
| | | | | | | | - Panagiotis Mavros
- Merck Sharp & Dohme Corp, Whitehouse Station, NJ, USA
- Global Health Outcomes, Merck Sharp & Dohme Corp, Mail: WS2E76, 1 Merck Drive, Whitehouse Station, NJ 08889, USA
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Ratanawongsa N, Crosson JC, Schillinger D, Karter AJ, Saha CK, Marrero DG. Getting under the skin of clinical inertia in insulin initiation: the Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project. Diabetes Educ 2012; 38:94-100. [PMID: 22222513 PMCID: PMC3557962 DOI: 10.1177/0145721711432649] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this cross-sectional study is to explore primary care providers' (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs. METHODS As part of the Translating Research Into Action for Diabetes study, the authors conducted structured interviews in health systems in Indiana, New Jersey, and California, asking PCPs about the importance of insulin initiation and factors affecting this decision. The authors calculated proportions choosing each multiple-choice response option and listed the most frequently offered open-ended response categories. RESULTS Among 83 PCPs, 45% were women; 60% were white; and they averaged 13.4 years in practice. Four-fifths of PCPs endorsed guideline-concordant glycemic targets, but 54% individualized targets based on patient age, life expectancy, medical comorbidities, self-management capacity, and willingness. Most (64%) reported that many patients were resistant to new oral or insulin therapies due to fears about the therapy and what it meant about their disease progression. Two-thirds (64%) cited patient resistance as a barrier to insulin initiation, and 43% cited problems with patient self-management, including cognitive or mental health issues, dexterity, or ability to adhere. Eighty percent felt that patient nonadherence would dissuade them from initiating insulin at least some of the time. CONCLUSIONS PCPs perceived that patient resistance and poor self- management skills were significant barriers to initiating insulin. Future studies should investigate whether systems-level interventions to improve patient-provider communication about insulin and enhance providers' perceptions of patient self-management capacity can increase guideline-concordant, patient-centered insulin initiation.
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Affiliation(s)
- Neda Ratanawongsa
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jesse C. Crosson
- Department of Family Medicine and Community Health, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School
| | - Dean Schillinger
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco
- California Diabetes Program, California Department of Public Health
| | - Andrew J. Karter
- Epidemiology & Health Services Research, Division of Research, Kaiser Permanente
| | - Chandan K. Saha
- Division of Biostatistics, Department of Medicine, Indiana University School of Medicine
| | - David G. Marrero
- Division of Endocrinology & Metabolism, Indiana University School of Medicine
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Abstract
Despite some progress in reducing the rate of diabetic complications, the epidemic rise in incidence of diabetes mellitus ensures that there will be an increasing number of patients in the coming decades with complex health care management issues who will need efficient and effective care. The management of patients with diabetes is an ever-challenging endeavor attributable to several factors. These include, among others, (1) limited provider expertise, (2) decreasing time of a patient visit, (3) increasing complexity of drug management, (4) limited use of self-monitoring of blood glucose by patients and/or providers, (5) clinical inertia, and (6) nonadherence. Technology-driven innovative solutions, including those using virtual reality, are desperately needed to assist both patients and their providers in overcoming the exigencies of this protean disease.
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Affiliation(s)
- Robert A Vigersky
- Diabetes Institute, Endocrinology Service, Walter Reed Health Care System, Washington, DC, USA.
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Abstract
As obesity and Type 2 diabetes mellitus reach epidemic proportions worldwide, glycemic control and prevention of complications have become even more critical. We searched studies published between January 2006 and January 2010 to identify and discuss the challenges facing healthcare professionals and patients in reaching glycemic targets. MEDLINE and Derwent Drug File searches were conducted with the following search terms: Type 2 diabetes mellitus, medication adherence, antihyperglycemic agents, glucose control, and clinical inertia. In this article we will outline the commonly used medications and present the advantages and disadvantages of each class of drug. Additionally, we will present the dipeptidyl peptidase-4 inhibitors and their place in the treatment of patients with Type 2 diabetes mellitus.
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Affiliation(s)
- Marie T Brown
- a Department of Internal Medicine, Rush University Medical Center, 6326 West Roosevelt Road, Oak Park, IL 60304, USA.
| | - Derek LeRoith
- b Division of Endocrinology, Diabetes & Bone Diseases, Mount Sinai School of Medicine, NY, USA
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Abstract
Blood pressure (BP) control is a critical part of managing patients with type 2 diabetes. Perhaps it is the single most important aspect of diabetes care, which unlike hyperglycemia and dyslipidemia can reduce both micro- and macrovascular complications. Hypertension is more prevalent in individuals with diabetes than general population, and in most cases its treatment requires two or more pharmacological agents (about 30% of individuals with diabetes need 3 or more medications to control BP). In this article we describe the key evidence that has contributed to our understanding that reduced BP translates into positive micro- and macrovascular outcomes. We review the data supporting current recommendation for BP target < 130/80 mmHg. Two studies suggest that a lower BP goal could be even more beneficial. We also present the comparative benefits of various antihypertensive drugs in reducing diabetes-related micro- and macrovascular complications. Finally we propose an evidence-based algorithm of how to initiate and titrate antihypertensive pharmacotherapy in affected individuals. Overall, achieving BP < 130/80 mmHg is more important than searching for the “best” antihypertensive agent in patients with diabetes.
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Affiliation(s)
- Gerti Tashko
- Division of Endocrinology, Diabetes, and Metabolism, Penn State College of Medicine, Hershey, PA, USA
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Abstract
RATIONALE, AIMS AND OBJECTIVES The use of general clinical guidelines versus customization of patient care presents a dilemma for clinicians managing chronic illness. The objective of this project is to investigate the claim that the performance of customized strategies for the management of chronic illness depends on accurate patient categorization, and inaccurate categorization can lead to worse performance than that achievable using a general clinical guideline. METHODS This paper is based on an analysis of a basic utility model that differentiates between the use of general management strategies and customized strategies. RESULTS The analysis identifies necessary conditions for preferring general strategies to customized strategies as a trade-off between strategy performance and the probability of correct patient categorization. The analysis shows that customized treatment strategies developed under optimal conditions are not necessarily preferred. CONCLUSIONS Results of the analysis have four implications regarding the design and use of clinical guidelines and customization of care: (i) the balance between the applications of more general strategies versus customization depends on the specificity and accuracy of the strategies; (ii) adoption of clinical guidelines may be stifled as the complexity of guidelines increases to account for growing evidence; (iii) clinical inertia (i.e. the failure to intensify an indicated treatment) can be a rational response to strategy specificity and the probability of misapplication; and, (iv) current clinical guidelines and other decision-support tools may be improved if they accommodate the need for customization of strategies for some patients while providing support for proper categorization of patients.
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Affiliation(s)
- Peter J Veazie
- Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Kristensen JK, Stoevring H. A follow-up study of the occurrence and consequences of HbA1c measurements in an unselected cohort of non-pharmacologically treated patients with Type 2 diabetes. Scand J Prim Health Care 2008; 26:57-62. [PMID: 18297565 PMCID: PMC3406631 DOI: 10.1080/02813430801892532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES To describe the occurrence of HbA1c measurements among non-pharmacologically treated diabetes patients, and to evaluate whether poor blood glucose regulation (HbA1c >8%) prompted intensification of treatment. METHOD Data from the National Health Service Registry, the Regional Laboratory Database and the Danish National Hospital Registry were collected from 2002 to 2004 to identify and describe all Type 2 diabetic patients above 40 years of age in a background population of nearly 660,000 citizens in Aarhus County, corresponding to 12% of the total Danish population. RESULTS A total of 1989 had at least one HbA1c measurement, whereas 484 (20%) had no HbA1c measurement at all in 2003. Most patients had an HbA1c of less than 8%, and for 820 (41%) HbA1c was less than 6.5%, but for 316 (16%) patients, the first HbA1c measurement in 2003 was above 8%. After 6 months, patients with HbA1c above 8% had a higher probability of initiating pharmacological treatment (M; 0.64; 95% CI 0.58-0.70) (F; 0.68; 95% CI 0.58-0.77) than patients with HbA1c below 8% (M; 0.12; 95% CI 0.10-0.14) (F; 0.11; 95% CI 0.09-0.14). CONCLUSION This study indicates that poor blood glucose regulation (HbA1c >8%) prompted a shift from non-pharmacological treatment to pharmacological treatment for most patients. However, a substantial group of patients are either not monitored on a regular basis or, if monitored, their elevated measurements of HbA1c do not prompt initiation of pharmacological treatment.
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Safford MM, Shewchuk R, Qu H, Williams JH, Estrada CA, Ovalle F, Allison JJ. Reasons for not intensifying medications: differentiating " clinical inertia" from appropriate care. J Gen Intern Med 2007; 22:1648-55. [PMID: 17957346 PMCID: PMC2219839 DOI: 10.1007/s11606-007-0433-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 08/16/2007] [Accepted: 09/09/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND "Clinical inertia" has been defined as inaction by physicians caring for patients with uncontrolled risk factors such as blood pressure. Some have proposed that it accounts for up to 80% of cardiovascular events, potentially an important quality problem. However, reasons for so-called clinical inertia are poorly understood. OBJECTIVE To derive an empiric conceptual model of clinical inertia as a subset of all clinical inactions from the physician perspective. METHODS We used Nominal Group panels of practicing physicians to identify reasons why they do not intensify medications when seeing an established patient with uncontrolled blood pressure. MEASUREMENTS AND MAIN RESULTS We stopped at 2 groups (N = 6 and 7, respectively) because of the high degree of agreement on reasons for not intensifying, indicating saturation. A third group of clinicians (N = 9) independently sorted the reasons generated by the Nominal Groups. Using multidimensional scaling and hierarchical cluster analysis, we translated the sorting results into a cognitive map that represents an empirically derived model of clinical inaction from the physician's perspective. The model shows that much inaction may in fact be clinically appropriate care. CONCLUSIONS/RECOMMENDATIONS Many reasons offered by physicians for not intensifying medications suggest that low rates of intensification do not necessarily reflect poor quality of care. The empirically derived model of clinical inaction can be used as a guide to construct performance measures for monitoring clinical inertia that better focus on true quality problems.
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