“Clinical inertia” is defined as a failure to initiate or intensify treatment in a timely manner in people with diabetes whose health is likely to improve with this intensification [1]. This definition has recently been expanded to include a failure: to establish appropriate targets; to escalate or de-escalate treatments in order to achieve treatment goals; and to prevent over-treatment in recognition that for some people with diabetes, particularly frail older adults, overtreatment can cause significant harm through hypoglycemia or weight gain [2]. The phenomenon is well described around the world and with approximately 80% of the population in the UK and USA not achieving clinical targets, despite the advances in therapeutic options; it poses the very important question: “Does clinical inertia matter?”
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Does clinical inertia matter?
Observational studies provide convincing data of the adverse effects of clinical inertia. The EURO-Heart survey, for example, diagnosed 452 new cases of diabetes of whom, 12 months later, 375 were maintained on diet and exercise alone. Of these, 43 individuals (11.5%) experienced major adverse cardiac events compared with only two out of those who received treatment [3]. In this case, the “wait until next clinic” effect resulted in an almost 10% increase in absolute event rate. Even when patients are started on antidiabetic drugs, failure to intensify treatment within a year among those whose glycated hemoglobin (HbA1c) levels remain at 53 mmol/mol (7%) or higher increases the risk of myocardial infarction by 67%, stroke by 51%, heart failure by 64%, and composite cardiovascular events by 62% [4]. These observations support the notion that clinical inertia has a significant impact on the health of people with diabetes.
What causes clinical inertia?
Having established the importance of clinical inertia, the next question is often how best to tackle it. However, before attempting to treat any condition, we need to know the underlying cause(s). In the case of clinical inertia, the causes can be broken down broadly into three areas:
- Physician
- Systemic factors
- Patient
Physician factors
As physicians, we are adept at identifying clinical inertia in our peers. However, we consistently overrate the quality of care that we ourselves provide, substantially underestimating the number of our own patients that are not meeting targets. When challenged with evidence of clinical inertia, we can be prone to making “soft excuses” for the avoidance of intensification: a lack of time to adequately discuss the new strategy; blaming the patient for non-adherence; or adopting a paternalistic approach.
Further, guidelines have not kept pace with the increasing number of therapeutic options and often fail to provide clear indications of which drug is suitable for which patient [5]. Guidelines can also complicate the management strategy of diabetes by recommending individualized treatment goals without clear instructions as to how to establish these goals. Paradoxically, the drive to individualize care actually encourages clinical inertia through lack of clarity [6].
Systemic contributors to clinical inertia
Time constraints in clinical practice contribute to delays in therapy intensification that are not seen in clinical trials [7]. Clinical trials offer extended, frequent visits and demonstrate a significant “placebo-effect” that is not replicated in the real world. Unlike quality of life measures, glycemic control is unlikely to be directly affected by the duration of patient/physician contact time [2]. However, increased frequency of visits and engagement may offer other mechanisms for reduction of clinical inertia.
Patient factors
No person with diabetes, nor any other chronic disease, would deliberately endanger their own health. However, only one-third of people with diabetes take at least 80% of their drugs for diabetes [8]. Reasons for this include:
- a lack of understanding of their management plan;
- a feeling of fatigue with complex treatment regimen; and
- a basic lack of understanding as to what the drug is actually for [9, 10].
The Time2DoMore survey provided evidence that hurried communication was a significant contributor to the lack of patient understanding of their pharmacotherapies [11]. Time2DoMore was a multinational survey, across the USA, UK, Spain, Brazil, India, and Japan, that explored the opinions of people with diabetes and their healthcare providers. This study highlighted concepts generally accepted to be “common knowledge” by physicians: that people with diabetes lacked understanding of their disease, including the significance of the diagnosis, the importance of diet and exercise and the purpose of treatment to reduce the risk of complications. Interestingly, the countries with the longest consultation periods (specifically Brazil) had the highest adherence to medications [12]. Communication without purpose, however, is not a goal. Only when the communication results in the patient empowerment to control their diabetes can it be regarded as being successful.
Working with patients to overcome clinical inertia: Lessons from co-production
There remain multiple challenges to ensure that people with diabetes receive, and then actually adhere to, the best treatment for them. Healthcare providers need to use all available resources to overcome these challenges. The role that the person with diabetes plays in delivering their own healthcare is a useful resource in tailoring care to the individual patient. The concept of “co-production” is a way of applying this to clinical inertia.
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Co-production in diabetes care
In its simplest form, co-production recognizes that the consumers of a service – diabetes care in this case – are both people with diabetes and healthcare practitioners. This is a concept that should be familiar to all healthcare providers, whereby the patient forms an essential component of ensuring effective healthcare delivery [13]. Health systems rely on the involvement of patients to ensure that the treatments determined by clinicians are carried out, by working together in the context of the wider environment. A person with diabetes is not just a passive recipient of healthcare – they are also a vital contributor to the success of any treatment recommendations. However, in order to work together as effectively as possible, the clinician and person with diabetes must first agree on the goals for treatment and how to achieve them.
Shared goals are key to co-production
Establishing shared goals between the individual with diabetes and the clinician is not as easy as it may first appear. The clinician and patient do not necessarily share priorities and are motivated by different factors [14]. For example, most guidelines advocate cardiovascular disease risk management as a priority in diabetes care [15, 16], whereas diabetes patients are often more concerned by the risk of retinopathy [11], hypoglycemia and weight gain [17]. These ambitions are not always clear, or may seem irrelevant to the clinician’s treatment goals [18]. Even when treatment goals are shared, people with diabetes and their healthcare providers may disagree on how these goals should be achieved or prioritized.
Managing a chronic illness such as diabetes is time consuming and can affect every aspect of a person’s life. Again, because of differing perspectives, the clinician may not always consider all facets of the patient’s journey, instead focusing on the need for adherence. Strict adherence to medication timings or dietary restrictions risks precipitating social isolation. It is therefore, unsurprising that individuals do not strictly follow every aspect of the advice given [8, 11]. The challenge for clinicians is to try and negotiate shared goals which meet both disease outcomes and the patient’s priorities [19]. An individual is much more likely to adhere to treatments and interventions that are aligned with their own priorities in the context of their wider lives. Recognizing the effects that chronic health problems have on peoples’ lives goes some way to allowing these goals to develop.
Building trust
There is no guarantee that discussion of these goals will result in agreement; however, unless the person with diabetes feels able to communicate openly and honestly, no discussions can take place. Good communication between physicians and patients can facilitate such discussions and establishes trust within the wider diabetes healthcare team. Including the family and caregivers of the person with diabetes is often an essential requirement if patients are to be equal partners in co-producing their health. All parties need to be able to have open and honest discussions about their concerns and priorities if they are to agree on shared goals and how they can be achieved [13]. Establishing such a relationship between clinician and patient takes time [14]. Without it, however, the person with diabetes may not reveal concerns over non-adherence, challenges with adherence to lifestyle measures and medications, or differing treatment goals.
Moving forward
Despite these challenges, co-production presents great opportunities to engage people with diabetes with their own care while meeting their own treatment priorities. Supporting them to take more control over the management of their diabetes can be difficult for clinicians, who may be concerned about losing control [20]. However, healthcare is already reliant on the actions of individuals with diabetes, who have their own priorities in managing their diabetes. Rather than presenting a new model of healthcare, co-production provides a way of recognizing the role that patients play in delivering their own health and supports their role in self-care (Box 1).
| Box 1: Practical guidance for effective communication |
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Summary
Clinical inertia is common in all chronic diseases, including diabetes. Despite the plethora of new agents for the management of hyperglycemia, hypertension, and dyslipidemia, the number of people with diabetes hitting all three targets remains low. The causes of clinical inertia are multifactorial, with contributory elements from people with diabetes, physicians, and the system within which they work. A potential reversible contributor to clinical inertia is the communication between physicians and people with diabetes.
The co-production model of open communication encourages discourse in both directions, allowing the person with diabetes to understand the gravity of their diagnosis and engage in treatment options. Improving engagement will allow the healthcare team to establish shared goals that are important to all team members, and to agree acceptable risks in order to achieve these goals. Only once people with diabetes are allowed to take full ownership of their disease and actively participate in decision-making can they take control of their disease and improve their outcomes.