Keywords
clinical inertia - clinical inertia at patient care level - clinical inertia at population
- diagnostic inertia - reverse clinical inertia - therapeutic inertia
Introduction
Various landmark trails showed that tight glycemic control reduces diabetes-related
long-term complications. However, a significant proportion of people with diabetes
on regular treatment and follow-up fail to achieve treatment target. Clinical inertia
is one of the major contributing factors for this.
Clinical Inertia
Clinical inertia is defined as inability or failure of health care providers to initiate
or intensify therapy when it is actually indicated.[1] In other words, it is “recognition of the problem, but failure to act.”
It is an “evidence practice gap.” Evidence practice gap is defined as the “difference
between what we know from the best available research evidence and what actually happens
in current practice.”[2] In other words, it is the gap between the best current practice recommendation and
the level of care the patient received. In people with suboptimal glycemic control,
if one is adding an agent that is unlikely to achieve glycemic target, that also contributes
to clinical inertia.[3]
The term “clinical inertia” was first coined by Phillips et al in 2001, and the term
“therapeutic inertia” was introduced by Okonofua et al in 2006.[1]
[4] Various terms such as “therapeutic inertia,” “physician inertia,” and “diagnostic
inertia” are synonymously used with clinical inertia. However, some experts define
it differently. Diagnostic inertia is defined as failure to consider the diagnosis,
when it really exists,[5] whereas therapeutic inertia is defined as failure of providers to begin new medications
or increase dosages of existing medications when an abnormal clinical parameter is
recorded.[4]
Another term related to this is “clinical myopia.” The failure to give preference
to the long-term benefits of treatment intensification may represent a common mechanism
underlying both patient’s nonadherence and physician’s clinical inertia. Such failures
are called “clinical myopia.”[6] Therapeutic momentum is defined as the reluctance to step down or withdraw therapy
when further prescription is not required or not supported by evidence.[7]
Clinical inertia also may apply to the failure of physicians to stop or reduce therapy
which is no longer required. Such inertia is called reverse clinical inertia.[8] Failure to de-intensify therapy when appropriate is important in people with frail
diabetes phenotype, which includes elderly individuals; underweight individuals; those
having long duration of diabetes; and those having underlying heart disease, stroke,
or renal insufficiency.[9]
Clinical inertia exists in all stages of development of diabetes starting from the
development of risk factors, stage of pre-diabetes to the stage of end-organ failure
due to diabetes[10] ([Table 1]). Health care professional has got a pivotal role in the prevention and progression
of diabetes at each stage. Population-based approach to prevent the development of
risk factors reduces the chance of development of pre-diabetes and overt diabetes
in the society.[10] Early screening of those with risk factors helps diagnose diabetes early. Proper
treatment of diabetes during initial years of diagnosis is associated with long-term
cardiovascular beneficial effect that is called “legacy effect.” Strict glycemic control
and control of other cardiovascular risk factors reduce the risk of diabetes-related
long-term complications. In people with long-term diabetes, screening for long-term
complication results in early identification of the complication and opportunity to
prevent its further progression.[10] In patients with long-term complications, aggressive management results in reduction
of morbidity and mortality. Clinical inertia at all these stages results in increase
in the global burden of diabetes and diabetes-related complications.[10]
Table 1
Overview of clinical inertia in the management of diabetes
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Overview of clinical inertia in the management of diabetes
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Clinical inertia at population level
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Clinical inertia to follow healthy lifestyle, e.g., eating habits, physical activity
|
|
Clinical inertia to screen for diabetes and other lifestyle disorders
|
|
Clinical inertia at patient level
|
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Clinical inertia to initiate and intensify lifestyle modification
|
|
Clinical inertia to initiate and intensify oral antidiabetic agents
|
|
Clinical inertia to initiate and intensify injectable antidiabetic agents
|
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Clinical inertia to monitor glycemic status regularly
|
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Clinical inertia to screen for long-term complications of diabetes
|
|
Clinical inertia to initiate and intensify treatment for long-term complications of
diabetes
|
|
Clinical inertia to modify antidiabetic medication in people with long-term complications
of diabetes
|
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Clinical inertia to redefine treatment targets in frail diabetes phenotype
|
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Clinical inertia to deescalate therapy in frail diabetes phenotype
|
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Clinical inertia to screen for other comorbid conditions, e.g., hypertension, dyslipidemia
in people with diabetes
|
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Clinical inertia to initiate and intensify treatment for other comorbid conditions,
e.g., hypertension, dyslipidemia in people with diabetes
|
Clinical inertia exists not only in the area of glycemic control but also in glycemic
monitoring and identification and treatment of chronic complications of diabetes.
In people with diabetes, management of other cardiovascular risk factors such as hypertension,
dyslipidemia, and obesity is also important. Clinical inertia exists in the management
of these conditions contributing to increased risk of cardiovascular morbidity and
mortality. Clinical inertia exists in all the stages of management of diabetes including
initiation of lifestyle modification, initiation, and intensification of oral antidiabetic
drugs and initiation and intensification of injectable agents including insulin.
Clinical Inertia at Population and at Patient Care Level
Depending on the level of clinical inertia, it can be of two types: clinical inertia
at population level and clinical inertia at patient care level ([Table 2]). Creating awareness about healthy lifestyle, prevention of development of risk
factors such as obesity, prevention of development and progression of pre-diabetes,
and early case detection by population-based screening is mainly done at community
level. However, in people with diabetes; failure to intensify therapy contributes
to clinical inertia at patient care level ([Fig. 1]). It can be due to provider-, patient-, or system-related issues.[11] Clinical inertia at population level usually reflects inadequate preventive care
where as clinical inertia at patient level reflects inadequate patient care.
Table 2
Comparison between clinical inertia at population level and at patient care level
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Clinical inertia at population level
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Clinical inertia at patient care level
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Failure to improve awareness about healthy lifestyle and need for screening of lifestyle
disorders in the population
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Failure to intensify therapy in people with diabetes
|
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Failure to motivate people to lead healthy lifestyle and early disease screening
|
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Reflect the quality of preventive care
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Reflect the quality of patient care
|
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Achieved mainly with nonpharmacologic interventions and lifestyle modifications
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Achieved mainly with pharmacologic therapy
|
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Inertia in activities like creating awareness about healthy lifestyle in the society,
prevention of development of risk factors, e.g., obesity, prevention of development
and progression of pre-diabetes, early case detection by population-based screening
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Inertia in activities, e.g., initiation and intensification of antidiabetic medications,
regular monitoring of glycemic control, monitoring and treatment of other comorbidities,
and diabetes-related complications
|
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Inertia in population-based interventions
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Inertia in hospital-/clinic-based interventions
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Tackling clinical inertia reduces the burden of diabetes in the population
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Tackling clinical inertia reduces the morbidity and mortality associated with poor
glycemic control
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Tackling clinical inertia reduces the risk of other lifestyle problems, e.g., hypertension,
dyslipidemia, and obesity
|
Tackling clinical inertia reduces the risk of diabetes-related complications and associated
comorbidities, e.g., hypertension, dyslipidemia, etc.
|
Fig. 1 Different aspects of clinical inertia.
The excess blood sugar level to which people with diabetes get exposed because of
clinical inertia is called “glycemic burden.” The part of glycemic burden after the
first out of target hemoglobin A1C (HbA1C) is called “avoidable glycemic burden,” and the remaining part of the glycemic burden
is called “unavoidable glycemic burden.”[12] Early diagnosis and timely initiation and intensification of antidiabetic therapy
reduce glycemic burden.[13] Inability to monitor glycemic status regularly delays treatment intensification
resulting in excess “glycemic burden.”
Emerging Concepts Regarding Clinical Inertia
In some people with diabetes, blood sugar values fluctuate widely. The degree of fluctuation
of blood glucose level is called glycemic variability (GV). Various studies show that
frequent or large glucose fluctuations may independently contribute to diabetes-related
complications.[14] Therefore, inability to reduce GV also contributes to clinical inertia.
Time in range (TIR) is another new concept that is defined as a measure of time where
the blood glucose remains within the proposed target range.[15] Therefore, inability to attain the TIR targets also contributes to clinical inertia.
Clinical inertia contributes to poor glycemic control in people with diabetes, resulting
in exposure to high blood sugar level for months to years. In other words, clinical
inertia results in increased risk of development of various complications. One analysis
showed that 80% of heart attacks are the result of clinical inertia in the management
of diabetes, hypertension, and dyslipidemia.[11] Addressing the issues of clinical inertia in diabetes helps reduce diabetes-related
morbidity and mortality.
Conclusion
Clinical inertia exists in all stages of management of diabetes. Clinical inertia
at population level reflects the quality of preventive care where as clinical inertia
at patient level reflects the quality of treatment offered to the patients. Addressing
the issues of clinical inertia helps reduce diabetes-related complications.
