Approaches to Reduce Therapeutic Inertia in Diabetes Management

Educational interventions led by nurses, pharmacists, and certified diabetes educators (CDEs) were found to be effective at reducing “therapeutic inertia” and ultimately blood glucose levels among patients with type 2 diabetes, according to research results published in Diabetes, Obesity and Metabolism.

Diabetes mellitus is a growing global health threat associated with a high incidence of morbidity and mortality, poor quality of life, and increased health care spending. Effective treatments are available to control the condition and help patients achieve glycemic targets while lowering hemoglobin A_1c (HbA_1c), a marker for blood glucose that is also predictive of vascular outcomes.

Improvements in reaching glycemic targets in diabetes have largely slowed, likely due to “therapeutic inertia,” a term used to define the failure of clinicians or other providers to intensify or deescalate therapy when appropriate. Therapeutic inertia in diabetes is a result of several patient-, provider-, and system-level factors.

In a meta-analysis, researchers sought to identify interventions that have been used to overcome therapeutic inertia in the setting of type 2 diabetes. Only studies published in peer-reviewed journals between 2004 and 2019 were included in the analysis.

The meta-analysis included 36 randomized controlled trials and quasi-experimental studies that assessed the effect of different strategies used to control HbA_1c.

Studies reporting on pharmacist-based interventions for mitigating therapeutic inertia focused on strategies led by pharmacists that provided medication therapy management services, increased autonomy for medication review, and enabled guideline-based medication adjustments. Physician-based interventions focused on physician education and practice improvement programs to influence treatment behavior regarding diabetes management. Nurse- and CDE-based interventions guided clinical staff in using evidence-based protocols for diabetes management, which included initiation and intensification of treatment. Care management and patient education interventions comprised virtual coaching and telemonitoring/telehealth in the form of alerts, shared decision-making tools, and embedded practice advisories in patients’ electronic health records.

For quantitative analyses, the primary outcome of interest was the mean difference in HbA_1c change between those in intervention groups vs those in control groups.

Overall, nurse- and CDE-based interventions resulted in greater HbA_1c reductions compared with those seen in control groups. The nurse- and CDE-based interventions were associated with a mean difference in HbA_1c ranging from -17.7 mmol/mol (-1.62%) to -4.4 mmol/mol (-0.40%). The mean reductions for pharmacist-based interventions ranged from -9.8 mmol/mol (-0.90%) to -6.6 mmol/mol (-0.60%).

The corresponding estimates for HbA_1c reductions ranged from -13.1 mmol/mol (-1.20%) to 3.3 mmol/mol (0.30%) for care management and patient education interventions and -4.4 mmol/mol (-0.40%) to 2.8 mmol/mol (0.26%) for physician-based interventions.

The median duration of interventions across studies was 1 year but ranged from 0.9 to 36 months. The pooled HbA_1c reduction at 6 months was -4.2 mmol/mol (95% CI, -6.2 to -2.2), and the corresponding value at 1 year was -1.6 mmol/mol (95% CI -3.3 to 0.1). The reduction in HbA_1c was significantly different between the types of interventions (P <.0001).

A potential limitation of this study was the inclusion of patients who were using different medication management strategies to address therapeutic inertia. For instance, some patients had their insulin initiated or intensified, while patients in other studies had their oral medications and/or injectable medications initiated or intensified. The meta-analysis did not include studies that reported or focused on medication adherence.

The investigators concluded that “therapeutic inertia can be mitigated by empowering pharmacists, nurses and diabetes educators with the ability to initiate and intensify treatment, supported by appropriate guidelines, protocols and collaborative agreements.”

Furthermore, although strategies that focus on changing clinician practices and those that use technology to forge communication between health care teams and patients are necessary, they “may not be sufficient to address therapeutic inertia in diabetes management.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Powell RE, Zaccardi F, Beebe C, et al. Strategies for overcoming therapeutic inertia in type 2 diabetes: a systematic review and meta-analysis. Diabetes Obes Metab. Published online June 27, 2021. doi:10.1111/dom.14455