Primary Care Research

Clinical inertia in primary care contributes to poor diabetes control

Clinical inertia—the failure to intensify therapy by increasing the dosage or number of appropriate medications—contributes to high HbA1c (blood glucose) levels in adults with type 2 diabetes treated in a large municipal hospital primary care clinic, concludes a new study supported by part by the Agency for Healthcare Research and Quality (HS07922).

Researchers compared the care of predominantly black patients with type 2 diabetes receiving treatment at a medical clinic with similar patients being treated at a diabetes clinic. They measured patients' blood glucose during the visit, which was available to the provider during the visit, and data on the patients' current treatment recommendations at the time of the visit and medications prescribed at the end of the visit. Compared with patients from the diabetes clinic, patients at the medical clinic had worse glycemic control (higher blood glucose levels), were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated, regardless of the type of therapy they received.

Use of diet and oral agents alone was somewhat higher for patients in the medical clinic, but use of insulin was significantly lower in the medical clinic than in the diabetes clinic (40 versus 55 percent). When glucose levels exceeded 150 mg/dL, therapy was half as likely to be intensified for patients in the medical clinic as it was for patients in the diabetes clinic (32 versus 65 percent), even though average HbA1c levels were higher for patients in the medical clinic. Providers who intensified therapy more often tended to have patients with lower HbA1c levels. A single episode of intensification of therapy was independently associated with an average 0.7 percent reduction in HbA1c.

See "Clinical inertia contributes to poor diabetes control in a primary care setting," by David C. Ziemer, M.D., Christopher D. Miller, M.D., Mary K. Rhee, M.D., and others, in the July/August 2005 Diabetes Educator 31(4), pp. 564-571.

Editor's note: A related study found that a primary care-based quality improvement system achieved HbA1c and low-density lipoprotein reductions sufficient to reduce macrovascular and microvascular risk by about 50 percent. For more details, see Sperl-Hillen, J., and O'Connor, P.J. (2005, August). "Factors driving diabetes care improvement in a large medical group: Ten years of progress." American Journal of Managed Care 11(5)S, p. S177-S185.

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