WASHINGTON — Physicians and other health care providers who take care of diabetes patients can easily suffer from “clinical inertia,” but performance feedback might help improve their performance, according to one diabetes expert.
Clinical inertia is defined as “failure to institute or change therapy appropriately when more intensive management is indicated,” Catherine Barnes, Ph.D., said at the annual meeting of the American Association of Diabetes Educators.
This problem is usually not caused by unfamiliarity with practice guidelines or inadequate time for care, she noted. Instead, it usually occurs when providers use “soft” reasons to avoid intensifying therapy. For example, they tell the patient to “try the diet a little longer,” or they say that a particular study's results don't apply to their own patients. Such providers also usually don't have systems to encourage them to step up therapy, such as flow sheets or “stepped” care protocols, said Dr. Barnes, who is with the Grady Diabetes Clinic in Atlanta.
Both patients and providers are trained not to be really aggressive with diabetes therapy, she said. “Patients don't change their diet because they're used to high-fat [food], or because they say they can't afford sugar-free items,” said Dr. Barnes. “Socially, they complain about lack of family support. … Or they have trouble looking at food labels and at food exchanges.”
On the caregiver side, one likely cause of inertia is that the providers have no way of knowing how their patients are doing as a group. So the clinic conducted a study to see if giving feedback to providers would result in lower HbA1c readings for patients. Because the Grady clinic is run by nurses, who provide most of the care, the researchers focused on six nurses who saw a total of 1,171 patients over a 2-year period.
The patients had a mean age of 61; 64% were female, and 94% were black. The mean body mass index was 33.9, average diabetes duration was 12 years, and average HbA1c was 7.35%. A total of 7% of patients were being treated with diet alone; 33% were on oral medications alone or a combination of oral medications and diet therapy; 47% were on insulin alone, and 13% were on insulin plus diet therapy.
The first year of the study served as a comparison period; no feedback was given. By the end of the first year, the patients' average HbA1c rose slightly to 7.36%, an insignificant difference.
Starting in the second year, the nurses had 5-minute feedback sessions with a diabetes specialist every 3 weeks. The specialists told the nurses how their particular patients were doing as a group in terms of HbA1c levels and other tests, such as blood pressure and cholesterol. Feedback sessions were scripted and included some questions to help the nurses become active learners.
At the end of the 2 years, the average HbA1c had dropped to 7.24%, a significant difference. “In every case, after these report cards, the HbA1c of [each nurse's patients] had come down,” showing that they were more likely to intensify treatment if they were given feedback. The comments from the nurses were also positive, she added.
In addition to receiving feedback, physicians and other providers can take several steps to improve their care of diabetes patients, according to Dr. Barnes. “One thing you can do is [post] reminders of high values,” she said. “You can also give those numbers to patients, so the patient can become empowered to say, 'My A1c is 8.5; what can we do about this?'”