Do You Have “Clinical Inertia”? 10 Facts to Jumpstart Diabetes Care

With more patients who have diabetes choosing to visit convenient care locations, retail health clinicians need to be mindful of “clinical inertia, or the failure to intensify treatment in the face of unacceptable glycemic control. All providers do their best to provide good care, but patient hesitance can stymie providers. Let’s examine 10 facts that will encourage you to escalate treatment.

#1: At least 25% of patients who have diabetes are not at goal, and the American Diabetes Association (ADA) indicates it’s closer to 50%. An estimated 5 million patients remain out of glycemic control for an average of 7 years. The guiding principle when patients visit for care is, “If in doubt, check glucose levels.” If they’re elevated, act.

#2: More than 8 million American adults have diabetes but don’t know it. These patients’ risk for microvascular and macrovascular complications is unnecessarily high. Convenient care providers are well placed to screen at-risk patients. Again, drawing blood levels can identify these patients.

#3: When clinicians are aware of and follow the ADA Standards of Medical Care in Diabetes or American Association of Clinical Endocrinologists algorithm, patient outcomes improve. Both were revised in 2016. Find them at professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf or aace.com/publications/algorithm.

#4: The guidelines recommend intensifying glucose-lowering drug therapy sequentially every 3 months if patients’ hemoglobin A1C (HbA1C) remains out of normal range (<6.5). Tell this to patients, and ask them to return in 3 months. Show them how to monitor their blood glucose, and make them partners in their own care.

#5: Since 2005, the FDA has approved more than 20 new entities, fixed-dose combinations, and drug-device delivery methods for diabetes. This expands the selection of agents you can prescribe, and it allows you to employ polymedicine (meaning the rational use of more than one drug). In fact, most people with diabetes will need to use medications that have complementary mechanisms of action; the average person with type 2 diabetes will need 3 medications to achieve glycemic control.

#6: The ADA is encouraging multidisciplinary teamwork in the care process. If all clinicians work together, we can provide these services consistently and repeatedly:

· Discuss each diabetic patient’s unique presentation and goals with him or her

· Describe the various available interventions, and the patient’s preferences

· Have forward-looking discussions that identify the risks of loose control, and interventions that will be needed if the patient does not achieve tight control

· Discuss potential adverse effects and how to handle them

· Address product safety

Involve other clinicians in your care of patients with diabetes: call the pharmacist, communicate with the primary care physician, and discuss lab work aberrations with the medical technologist.

#7: Clinicians who practice at convenient care clinics provide chronic condition management as well as other providers, and patients are more likely to return for follow-up. Retail health providers can use this opportunity to help patients manage adverse effects and fine-tune treatment.

#8: Injectable drugs—insulin-based products, high-dose insulins, and injectable noninsulins&mdash;and their associated drug delivery devices are becoming standard of care. It’s important to put aside any preconceptions about injectable therapies&mdash;that patients will dislike the needle, that injectables are punishment for nonadherence to oral therapy, or that hypoglycemia risk increases. New delivery systems have made traditional insulin and insulin analogs easier to use, more convenient, and safer. And the needles are very fine.

#9. There are several new insulins, concentrations, and fixed-dose combination products. This can be confusing, but learning the basics can prevent error. Here are some key points:

· Basal insulin provides a background of insulin around the clock, independent of food intake.

· Long-acting basal insulins—such as insulin detemir, insulin glargine, and insulin degludec&mdash;begin working within an hour or 2 but are released gradually over 24 hours or longer.

· Availability of insulins in higher concentrations than previously manufactured make it easier for patients to administer high doses, and usually, these come in pen injectors that increase safety.

#10: Fewer than one-third of adults with type 1 diabetes reach HbA1C of 7% or lower. Diabetologists are starting to use the GLP-1 agonists and SGLT2 inhibitors in patients with type 1 diabetes. This is a paradigm shift, so be aware of it.

Patients tend to know more about the practicalities of their glucose-lowering regimens than do health care professionals who only see them periodically. Clinicians who practice in convenient care locations can forge strong alliances with patients to reach targets. Clinicians can also learn from their patients and apply what they learn to other patients.

Resources

American Association of Clinical Endocrinologists. AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2016. aace.com/publications/algorithm. Accessed October 23, 2016.

American Diabetes Association. Standards of Medical Care in Diabetes—2016. Available at care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf. Accessed February 23, 2016.

American Diabetes Association. Strategies for improving care.Diabetes Care.2016a;39(Suppl 1):S6-S12. doi.org/10.2337/dc16-S004.

Bode BW, Garg SK. The emerging role of adjunctive noninsulin antihyperglycemic

therapy in the management of type 1 diabetes.Endocr Pract.2016;22(2):220-230. doi: 10.4158/EP15869.RA.

Guo H, Fang C, Huang Y, Pei Y, Chen L, Hu J. The efficacy and safety of DPP4 inhibitors in patients with type 1 diabetes: A systematic review and meta-analysis.Diabetes Res Clin Pract.2016;121:184-191. doi: 10.1016/j.diabres.2016.08.022.

Miller E, Costello J. Overcoming patient barriers in glycemic control: clinical advances in combination glp-1 and insulin therapy.Pharmacy Timeswebsite.pharmacytimes.com/publications/issue/2016/june2016/overcoming-patient-barriers-in-glycemic-control-clinical-advances-in-combination-glp-1-and-insulin-therapy. Published June 16, 2016. Accessed February 22, 2017.

Polinski JM, Smith BF, Curtis BH, et al. Barriers to insulin progression among patients with type 2 diabetes: a systematic review.Diabetes Educ.2013;39(1):53-65. doi: 10.1177/0145721712467696.

Reid RO, Ashwood JS, Friedberg MW, Weber ES, Setodji CM, Mehrotra A. Retail clinic visits and receipt of primary care.J Gen Intern Med.2013;28(4):504-512. doi: 10.1007/s11606-012-2243-x.

Thygeson M, Van Vorst KA, Maciosek MV, Solberg L. Use and costs of care in retail clinics versus traditional care sites. Health Aff (Millwood). 2008;27(5):1283-1292. doi: 10.1377/hlthaff.27.5.1283.