Results: Previous studies suggest clinical inertia, defined as lack of treatment intensification in a patient not at goal, is largely responsible for the slow improvement seen in population measures of diabetes care. It is controversial how much of the inertia problem is attributable to providers, care systems, or patient preference.
An electronic visit-based decision support tool called Diabetes Wizard was successfully implemented in 6 HealthPartners Clinics from 10/06 through 5/07 as part of the NIDDK funded study entitled “ Reducing Clinical Inertia in Diabetes Care” (DK068314). The Wizard gave relevant clinical information and specific recommendations for treatment intensification for glycemia, BP, and lipids. In addition, 19 consented physicians in the clinics agreed to complete an electronic visit action resolution (VAR) form at each encounter if the patient was not at goal for glycemia, blood pressure, or lipids and treatment was not intensified. The VAR was completed by checking from a list of possible reasons or through free text.
Out of 1639 encounters with patients not achieving A1C less than 7%, the WIZARD was used and VAR completed 831 times (51%). Inertia occurred in 258 (43%) of the VAR completed visits. Reasons that were specified by physicians for glycemia inertia were: (1) Choice of patient not to increase or add medications, 70 (19.6%), (2) Need for an updated A1c, 62 (17.3%), (3) Followed by endocrinology or diabetes nurse, 53 (14.8%), (4) Addressed dietary/lifestyle changes instead, 45 (12.6%) (5) Other problem/acute illness addressed, 17 (4.7%), (6) not my patient, 13 (3.6%) (7) addressed adherence problem, 13 (3.6%). Other reasons that were sited less frequently (< 2.5%) were medication regimen already too complex, hypoglycemia concerns, drug intolerance, cost concerns, advanced age or severe co-morbidities, referred to endocrinology or diabetes educator, close to goal, and other miscellaneous reasons.
Only a relatively small amount, less than 20%, of total glycemia inertia at diabetes patient encounters is attributable to patient refusal or preference. The remaining reasons could potentially be addressed through care system changes, including point of care testing to assure up-to-date A1C test results are available at visits, provider training, and better coordination of care with the extended care team and primary provider colleagues.