Clinical Inertia in Individualising Care for Diabetes: Is There Time to do More in Type 2 Diabetes?

Whereas physicians are able to accurately identify clinical inertia in their peers, they consistently overrate the quality of the care they provide. Additionally, they substantially underestimate the number of their own patients that are not at targets. Physicians are also more prone to making “soft excuses” to avoid intensification; a lack of time to adequately discuss the new strategy, blaming the patient for non-compliance or adopting a paternalistic approach. Finally, many physicians may lack the appropriate support, knowledge or training to manage multiple chronic diseases. This is particularly true in the management of type 2 diabetes, where therapeutic options have expanded considerably in a relatively short time frame mirrored by substantial changes in guidelines. These guidelines further complicate the management strategy of diabetes, as physicians are increasingly recommended to individualise treatment goals. There are, however, no clear recommendations as to how to establish these goals. Paradoxically, therefore, the drive to individualise care actually encourages clinical inertia through lack of clarity.

There are three potential points on the pathway to good control where these can fail—setting the appropriate target, initiating appropriate treatment and modifying the treatment in response to outcomes.

Physicians tend to set targets based on treatment strategies with which they are most familiar, appropriate for the individual or not. To date there is only one study which has evaluated the feasibility of individualising treatment targets [9]. Despite being provided clear guidance on how to personalise targets, conventional targets of around 7% were still set, demonstrating inertia of a different sort—the reluctance to move away from conventional targets and therefore potentially overtreat certain individuals.

Individualising treatment targets often provides an opportunity for “false reporting” of success, allowing the goal to retrospectively move to meet achieved value. Often this may be appropriate and indeed these goals should be in a permanent state of flux reflecting the complex progressive nature of diabetes. However, in such time-varying processes, goals should reflect the anticipated changes. Such forward planning facilitates realistic target setting with appropriate thresholds for action. Clear documentation and review on a regular basis allows coordination whilst demonstrating the reality of individualising care.

Older guidelines that promoted universal algorithmic pathways triggered a different type of clinical inertia. When faced with such goals and protocols to achieve them, physicians often feel a sense of futility. Furthermore, this focus on goal-setting pathology management overshadows the need for appropriate action and grossly under-recognises the importance of basic communication between patient, physician and within the multidisciplinary team. This is particularly true in the primary care setting where physicians tend to operate in isolation. The resultant reactive, rather than proactive, approach to management leads to intensification of diabetes treatment, and specialist support is only requested once the glycaemic control has been lost and, in effect, waiting until complications have arisen before appropriate preventative strategies are engaged.

Time constraints further contribute to the delays in appropriate intensification of therapy [10]. Clinical trials offer extended, frequent visits demonstrating a significant “placebo-effect”. Unlike quality of life measures, glycaemic control is unlikely to be directly affected by the level of patient/physician contact time. However, increased frequency of visits and engagement may offer other mechanisms for reduction of clinical inertia. Regular scheduled visits encourage shorter-term goal setting with established timelines and planned interventions if these are not met.

Clinical trials have additional transferable features that may further reduce clinical inertia; trial protocols provide decision support that leaves little ambiguity about required interventions. The final, potentially transferable, lesson from clinical trials is the degree of accountability at each visit and introducing clear clinical record forms to facilitate adherence to protocols, requiring a systematic record of results, actions implemented and justifications of any deviations from the protocols.

The causes of clinical inertia do not solely lie with physicians. Non-adherence to lifestyle modifications and prescribed drug treatments is estimated to count up to nearly 100% [11]. The underlying reasons for this are unclear. Interestingly, social and environmental pressure may be the strongest modulators for “required” lifestyle changes. The importance of socio-economic factors for diabetes outcomes has recently been demonstrated by a population wide analysis of the consequences of weight loss and regain driven by an economic crisis in Cuba [12]. In this survey, an average population wide ~5.5 kg weight loss was associated with rapid significant declines in diabetes and heart disease prevalence, whereas a weight rebound led to a diabetes prevalence that even exceeded pre-crisis levels [12].

Patient understanding of, and engagement with, their treatment can be a crucial determinant of adherence [13] as it may be adversely influenced by attitudes, negative media publicity and resultant misperception [14, 15]. Although no research has demonstrated the role of positive media publicity, a logical extrapolation of this is that positive publicity may encourage a willingness to intensify treatment on behalf of the patient. This approach has been effective in conditions such as erectile dysfunction and stress incontinence and would be expected to reduce clinical inertia, particularly if the positive message is focused on diabetes rather than specific pharmaceutical agents.

Accountability between patient and physician is difficult, particularly as “soft reasoning” resulting in fewer tablets and less intensification is perceived as a positive outcome by the patient. However, considering the implications of chronic, inadequate metabolic control, personal and economic direct and indirect costs, several providers have elected to provide financial incentives for good metabolic control. In 2003, the UK National Health Service (NHS) renegotiated the primary care general practitioners’ contract to include a “pay-per-performance” scheme. This quality and outcomes framework (QOF) linked 129 indicators covering different areas including diabetes, and provided a pecuniary reward for achieving targets. Among these, 16 points, each worth £124.60, were awarded for achieving an HbA1c of at <7.5% in at least 50% of people with diabetes. This financial incentivisation of better metabolic control was associated with an increase from 39.7% in 2006 to 52.1% in 2008 of people with diabetes achieving an HbA1c of <7.5% in the UK. Additionally, the number of patients with poor control (i.e. >10%) reduced from 11.8% to 10.1%, suggesting the intervention had also improved the general approach to diabetes, not just chasing the 50% target to receive the reward. It must be acknowledged that this time period also saw the introduction of the dipeptidyl peptidase-4 (DPP-4) inhibitors, enabling targets to be achieved with less hypoglycaemia and weight gain, thereby making realising targets more acceptable to the people with diabetes. The process of incentivised management, however, did not necessarily provide additional doctor–patient contact time with the population as a whole. Therefore, to achieve these targets, increased time intervening in people with diabetes, may come at a cost of less time available to people with other non-incentivised long-term conditions, potentially to their long-term detriment.

Clinical trials usually commence with high-frequency screening visits, followed by a series of more frequent visits to initiate and intensify care, before a stabilised visit regimen approximately 3–4 months apart. These trials usually report good early glycaemic control that is sustained for the duration of the study. There are many reasons why this increased frequency of visits may improve control, beyond the increased opportunity to intensify care and better monitoring of response to therapy. The increased frequency, particularly at the outset of the disease, reinforces the severity of the disease to the persons with diabetes, thereby reducing resistance to escalate intervention. It offers the opportunity for regular educational input, in digestible packages, and allows development of a good rapport. Finally, the patient learns by experience that frequent review and adjustment of therapy is a part of good diabetes care rather than a sign of treatment failure. There are, of course, cost implications of increased frequency of visits, extra investigations and the increased prescribing, however, it would be anticipated that this would be ameliorated in the long-term by the reduced complications.