Clinical inertia in response to inadequate glycemic control: do specialists differ from primary care physicians?
OBJECTIVE
Diabetic patients with inadequate glycemic control ought to have their management intensified. Failure to do so can be termed "clinical inertia." Because data suggest that specialist care results in better control than primary care, we evaluated whether specialists demonstrated less clinical inertia than primary care physicians.


METHODS
Using administrative data, we studied all non-insulin-requiring diabetic patients in eastern Ontario aged 65 or older who had A1c results >8% between September 1999 and August 2000. Drug intensification was measured by comparing glucose-lowering drug regimens in 4-month blocks before and after the elevated A1c test and was defined as 1) the addition of a new oral drug, 2) a dose increase of an existing oral drug, or 3) the initiation of insulin. Propensity score-based matching was used to control for confounding between groups.


RESULTS
There were 591 patients with specialist care and 1,911 with exclusively primary care. In the matched cohorts, 45.1% of patients with specialist care versus 37.4% with primary care had drug intensification (P = 0.009). Most of this difference was attributed to specialists' more frequent initiation of insulin in response to elevated A1c.


CONCLUSIONS
Fewer than one-half of patients with high A1c levels had intensification of their medications, regardless of specialty of their physician. Specialists were more aggressive with insulin initiation than primary care physicians, which may contribute to the lower A1c levels seen with specialist care. Interventions assisting patients and physicians to recognize and overcome clinical inertia should improve diabetes care in the population.
Shah
Baiju R
BR
Institute for Clinical Evaluative Sciences, G106-2075 Bayview Ave., Toronto, ON, Canada M4N 3M5. baiju.shah@ices.on.ca
Hux
Janet E
JE
Laupacis
Andreas
A
Zinman
Bernard
B
van Walraven
Carl
C
D000368:Aged; D001786:Blood Glucose / Q000187:drug effects / Q000378:metabolism*; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000097:blood* / Q000188:drug therapy / Q000401:mortality; D005194:Family Practice; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D008297:Male; D008499:Medical Records; D008511:Medicine; D009864:Ontario; D018579:Patient Selection; D013038:Specialization; D016019:Survival Analysis; D017211:Treatment Failure
D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents