Developing a quality measure for clinical inertia in diabetes care.
OBJECTIVE
To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.


METHODS
Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.


METHODS
Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.


RESULTS
Increases in antiglycemic medications occurred at only 9.8 percent of visits despite 39 percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p < .001).


CONCLUSIONS
Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.
Berlowitz
Dan R
DR
ENRM VA Hospital, Bedford, MA 01730, USA.
Ash
Arlene S
AS
Glickman
Mark
M
Friedman
Robert H
RH
Pogach
Leonard M
LM
Nelson
Audrey L
AL
Wong
Ashley T
AT
D000368:Aged; D015897:Comorbidity; D048909:Diabetes Complications / Q000517:prevention & control; D003920:Diabetes Mellitus / Q000628:therapy*; D004363:Drug Utilization; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D017063:Outcome Assessment, Health Care / Q000379:methods*; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D012720:Severity of Illness Index; D014481:United States; D014493:United States Department of Veterans Affairs
D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin