Clinical inertia contributes to poor diabetes control in a primary care setting.
The purpose of this study was to determine whether "clinical inertia"-inadequate intensification of therapy by the provider-could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site.



In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured.



Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001).



Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.
Ziemer
David C
DC
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Miller
Christopher D
CD
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Rhee
Mary K
MK
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Doyle
Joyce P
JP
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Watkins
Clyde
C
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Cook
Curtiss B
CB
The Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, and Mayo Clinic, Scottsdale, Arizona (Dr Cook)
Gallina
Daniel L
DL
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
El-Kebbi
Imad M
IM
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Barnes
Catherine S
CS
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Dunbar
Virginia G
VG
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Branch
William T
WT
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
Phillips
Lawrence S
LS
Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
D001291:Attitude of Health Personnel; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000628:therapy*; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D010349:Patient Compliance; D011320:Primary Health Care / Q000592:standards*; D011785:Quality Assurance, Health Care
D006442:Glycated Hemoglobin