QUEBEC CITY — The management of diabetes is compromised by “clinical inertia” in responding to a patient's elevated hemoglobin A1c levels, according to a new study.
“Over half of the patients in our study were not prescribed any change at all in their medications after a poor HbA1c reading,” said Baiju Shah, M.D., of the Institute for Clinical Evaluative Sciences, Toronto. “This is what has been described in the literature as the phenomenon of clinical inertia—when the physician recognizes a problem but doesn't do anything about it.”
Dr. Shah's retrospective study analyzed the responses of physicians to their diabetes patients' elevated HbA1c results. He presented the findings in a poster at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.
The 1,170 patients were aged 65 years or older, had non-insulin requiring type 2 diabetes, and had an HbA1c level above 8%, indicating poor glycemic control.
A comparison was made of the medications prescribed to each patient during the 4 months preceding the unfavorable HbA1c test result and during the 4 months after the test.
Drug intensification was defined as the addition of a new oral drug, an increase in the dose of an oral drug, or the initiation of insulin.
“We were looking for any increase in medication. It didn't matter if it was inadequate, as long as there was some change indicating that the physician had responded to the test result,” Dr. Shah told this newspaper.
Half the patients were seeing primary care physicians (defined in Canada as mostly family physicians), and half were seeing endocrinologists, internists, or geriatricians (all classified as specialists in Canada).
Most of these patients with elevated HbA1c levels did not have an increase in medication (55% of patients seeing endocrinologists, internists, and geriatricians; 63% of patients seeing primary care physicians).
Although all physicians were about equal in terms of adding new oral drugs or increasing the dosage of oral drugs, there was a difference in their approach to initiating insulin.
Of patients seeing endocrinologists, intern-ists, and geriatricians, 9% were started on insulin, vs. 2% of patients seeing primary care physicians, he said.
The phenomenon of clinical inertia has been described in the context of other conditions such as hypertension and hypercholesterolemia, as well as in other aspects of diabetes care, he said.
“In this study, there is no question that a lack of medication adjustment in response to a poor HbA1c result could partly be the choice of the patients who were already taking a lot of medications and didn't want to add another,” he said.
“But many times, it is also the physicians,” Dr. Shah added. “They get distracted by other things that they need to address with the patient, or they may interpret a result as getting slightly better, when really it is not.”
