Clinical Inertia: A Barrier to Treating Diabetes
FEBRUARY 13, 2018
MD Magazine Staff
Serge Jabbour, MD: Studies have shown that many times, patients remain at high A1C levels for 2 to 3 years before a change is made in the regimen. That’s what they call inertia. As providers, sometimes we sit on high A1C; we don’t do anything about it. Why? Because of many factors. Patients can sometimes argue with us and say, “There were holidays. I had the wedding. My diet was not good. Please give me a chance.” We give them a chance. They come back, and there’s something else, or we get too busy.
With the way health care is, providers have to see more patients, and there’s less time to spend with each patient. Patients may not always attend diabetes education classes. Studies have shown that many providers may just sit and not be proactive with A1C levels, which are high for years before something is done. That’s why patients sometimes end up with high A1C for a long time with changes made slowly over time, and that’s including insulin. Even when insulin is added, A1C may not always come down to goal right away, because some patients could be severely insulin resistant. They might need changes and adjustments, and these could be made so slowly that it may take years for that to happen. That inertia is something we have to find in practice and really make changes to.
Davida F. Kruger, MSN, APN-BC, BC-ADM: I think what you have to understand about type 2 diabetes is that it’s a progressive disease. Over time, patients are going to need to have their therapies progress. Today, we might be on just metformin. There might be some other oral agents. But eventually, probably 80% of all our patients will need insulin. So, you can start insulin at the beginning of the career of diabetes or somewhere along the way, but they’re going to need insulin. What happens is, it’s not started. A1C levels are left to go too high. It’s put off too long, and the health care provider, as well as the patient, are not comfortable necessarily starting insulin. And so, patients are left with A1C levels that are too high. That’s too bad, because what we know is that those patients are the ones who are going to have complications.
When patients are started on insulin, we always say, “Go low, go slow,” because we don’t want to cause hypoglycemia. We want the patient to adjust, but it’s also important to up titrate the insulin. The patients can do that themselves. The patients can change the dose and titrate the dose; we just need to teach them how to do that.
If I start someone on a basal insulin of 10 units, I don’t want them to come back in 3 months and still be on 10 units. Either I need to teach them how to titrate or I need to titrate. But it’s important. It’s time-consuming, and you have to feel comfortable with insulin. So, I think those are the things that we need to be out in the community teaching people: how to use insulin, when to start it, the importance of not letting A1C levels run too high, and the fact the patients can titrate their own insulin.
Transcript edited for clarity.