Combatting Clinical Inertia in Diabetes Patients

Diabetes Mellitus (DM) is a worldwide growing problem with significant associated morbidity and mortality as well as financial burden. While the pharmacologic armamentarium for diabetes management has grown tremendously in recent years providing some patients with the newest and most beneficial therapeutic options, many patients unfortunately remain on older and outdated therapies long term or go without treatment for a variety of reasons. Furthermore an alarming number of patients may remain undiagnosed (1). A topic that I am passionate about relates to the intersection of clinical inertia with diabetes, and I will elaborate on this more specifically.

As an inpatient based endocrinologist I frequently encounter the following scenario. Endocrinology is consulted for a severely elevated HbA1c (typically > 9% and sometimes severely higher than that) in a patient with new onset DM. When asked if the patient has ever had diabetes diagnosed before, they adamantly state no. When discussion continues and the patient is pressed further they will often report that their primary care doctor mentioned that their glucose level was "borderline," but they were never told of having DM. Sometimes when pressed even further, the patient had been prescribed oral hypoglycemic medications in the past for the "borderline" sugar problem, or report an HbA1c over 7% and never told of DM. This, I believe is a huge disservice that many in the medical community are doing for their patients. Yes it is hard to give someone a diagnosis of diabetes. I do understand the desire to give our patients good news. But it is a necessary difficulty in order to help the patient appreciate the severity of the problem and initiate an appropriate response. It is easier to continue with a poor diet and lack of physical activity and sporadic follow up with a medical provider when the issue is borderline. When a diagnosis of DM is assigned it begins a trajectory that is still quite challenging but more likely to be successful. When I meet these patients with severely uncontrolled "newly diagnosed" DM who in actuality had DM for years and may be now experiencing complications from DM I am saddened by the unnecessary decline in these patients that might have been preventable. I make it a point when meeting such a patient in the hospital without a prior diagnosis of DM to very clearly state "You have diabetes." Once the knowledge is there the improvement and healing can begin.

Another related but separate problem relates to pharmacologic management of DM and clinical inertia. Clinical inertia in relation to DM is defined as the delay in treatment intensification despite suboptimal glycemic control (2-4). The prevalence of DM is beyond the capacity of endocrinologists, and so a large proportion of DM patients receive their DM management from a primary care provider. Some providers are not as versed with newer pharmacologic options and may be more comfortable prescribing some of the older oral DM agents (5-7). I meet many patients on the inpatient service, again with uncontrolled DM and when I obtain the history it seems that the HbA1c has remained high for a prolonged period of time. While not always, often enough it seems that their outpatient provider made only minor adjustments to oral medications in the face of severely elevated levels that would have warranted insulin therapy. Sometimes no adjustments were made to therapy but patients are given generic advice to do better and work harder on controlling their glucose levels but with pharmacologic therapy continued as is. Primary care providers are often not trained in or comfortable with the management of insulin, particularly given all the newer formulations and brands. It certainly is easier to maintain the status quo but when a patient has achieved an HbA1c > 9-10% it requires a closer look and consideration for more drastic pharmacologic adjustments. While referral to endocrinology is warranted, sometimes wait times for appointments can be months long, particularly in the NY area where I practice.

Now that I have raised several challenging problems it is my hope that more solutions can be found. Let us advocate for improved diabetes related training of our primary care providers who are our front line for a large portion of the DM community. Let us help them be more comfortable initiating a patient on basal insulin therapy or basal and bolus insulin therapy if warranted, not to mention use of our newer and organ protective pharmacologic classes including the GLP-1 receptor agonists and the SGLT2-inhibitors, with less reliance on sulfonylureas if possible. Let us encourage clear communication with patients regarding a diagnosis of diabetes mellitus when appropriate.  Furthermore now that the use of an inpatient diabetes team has become more widespread let us take advantage of inpatient resources for education to help high risk DM patients onto a better treatment path. For example at my institution a program of universal HbA1c screening in the emergency department observation unit was utilized to identify patients with HbA1c > 9% in need of an endocrine consult, frequently being newly initiated on injectable DM therapy with patient education and prescriptions provided prior to discharge (8).

It won’t be easy but we can do better. I look forward to hearing your thoughts or comments on this topic!

 

References:

  1. National diabetes statistics report, 2020. Centers for Disease Control and Prevention. Accessed January 18, 2021. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
  2. Okemah J, Peng J, Quiñones M. Addressing Clinical Inertia in Type 2 Diabetes Mellitus: A Review. Adv Ther. 2018 Nov;35(11):1735-1745.
  3. Ruiz-Negron N, Wander C, McAdam-Marx C, Pesa J, Bailey RA, Bellows BK. Factors associated with diabetes-related clinical inertia in a managed care population and its effect on hemoglobin A1C goal attainment: a claims-based analysis. J Manag Care Spec Pharm. 2019;25(3).
  4. Kallenbach L, Shui AM, Cheng WY, et al. Predictors and clinical outcomes of treatment intensification in patients with type 2 diabetes uncontrolled on basal insulin in a real-world setting. Endocr Pract. 2018;24(9).
  5. Shah BR, Hux JE, Laupacis A, ZinmanB, van Walraven C. Clinical inertia in response to inadequate glycemic control: do specialists differ from primary care physicians? Diabetes Care. 2005;28(3).
  6. Ho M, Marger M, Beart J, Yip I, Shekelle P. Is the quality of diabetes care better in a diabetes clinic or in a general medicine clinic? Diabetes Care. 1997;20(4).
  7. Perreault L, Vincent L, Neumiller JJ, Santos-Cavaiola T. Initiation and titration of basal insulin in primary care: barriers and practical solutions. J Am Board Fam Med. 2019;32(3).
  8. Schulman-Rosenbaum RC, Hadzibabic N, Cuan K, Jornsay D, Wolff E, Tiberio A, Gottlieb D, Davis F, Silverman RA. Use of Endocrine Consultation for Hemoglobin A1C ≥9.0% as a Standardized Practice in an Emergency Department Observation Unit.  Endocr Pract. 2021 Nov;27(11):1133-1138.
Rifka Schulman-Rosenbaum, MD, FACE, CNSC, Vice Chair, Diabetes Disease State Network