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This article was originally published in the September 2014 issue of Diabetes Voice.

In the study of physics, inertia describes resistance to movement. When applied to medicine, the word inertia similarly describes resistance to change. More specifically, it is the difference between the medical care that should be aspired to and what is actually achieved. Studies have shown that clinical inertia is a common problem in the treatment of type 2 diabetes (1). Despite the availability of more diabetes therapies than ever before, almost half of those treated still have difficulty controlling their blood glucose.

Clinical inertia definitions

What causes clinical inertia?

Diabetes is a complex, progressive disease, meaning it inevitably needs more treatment as time progresses. Clinical inertia can occur at any point along the path of diabetes, and it can only be overcome by doctors and people with diabetes acting together as a team. This is the cornerstone of the Time2DoMoreTM project.

The Time2DoMore project was published in Diabetes Research and Clinical Practice (DRCP) (2). This survey investigated the causes of diabetes-related clinical inertia in six countries: Brazil, India, Japan, Spain, UK and USA. A total of 337 doctors and 652 people with diabetes completed an online questionnaire. From the results obtained, we have issued four simple statements to people with diabetes that we believe can improve diabetes care around the world.

4-step pathway to improved health

Clinical inertia often begins at the time of diagnosis

Only about a third of people with diabetes who replied to our questionnaire were accepting of their diagnosis, and the majority had different reactions. Although doctors took time to emphasise the importance of good diabetes care to avoid the risk of complications such as heart and kidney disease, three quarters of people with diabetes said that they were not concerned about this risk or thought it was very small. Those who were, were most concerned about the risk of vision problems (Figure 1). Furthermore, whereas the majority of doctors felt they had sufficiently explained the risk of hypoglycaemia (hypos), fewer than one in ten people with diabetes were aware that hypos could be life-threatening. When asked specific questions about hypos, only around one in three people with diabetes said that they tell their doctor each time that they have a hypo and only 3% could answer all seven questions correctly (Figure 2). This is an example of a breakdown in communication that could cause problems in diabetes management. The first of our statements underpins the key to good diabetes control.

Clinical inertia figure 1
Figure 1: Reactions of people with diabetes to explanations of complications at diagnosis in the Time2DoMore survey.

Individualising care

The choice of medications for a person with diabetes is based on several factors such as age, other medical conditions and the functioning of the rest of the body, particularly the filtering ability of the kidneys. This brings us to the second statement for improved quality of life of people with diabetes.

The simple statement “Every person with diabetes is different” represents one of the most important factors in the management of diabetes. The management of diabetes that could save one person’s life could literally kill another. Of course, the physician’s choice can only be as good as the information they are provided with. The best way for the person with diabetes to establish individuality is: “tell your doctor about you”. The solution again is communication.

Clinical inertia figure 2
Figure 2: Responses of people with diabetes to a six-item hypoglycaemia quiz as part of the Time2DoMore survey.

What else can the person with diabetes do?

Empowerment through education is an essential step in improving health. In the Time2DoMore survey only approximately half of people planned to adjust their diet and less than 40% would follow the advice regarding physical activity, despite almost all physicians (96%) reporting that they recommend these lifestyle changes. This represents another well-recognised phenomenon – the misapprehension that: “the doctor is responsible for my diabetes”. The third statement addresses this component.

This does not absolve the physician or family members of their responsibility to provide the best possible support and treatment options, but recognises that at the centre is a person who has ultimate control over his or her health.

Even if both the person living with diabetes and their doctor have good intentions and have formed a partnership with shared treatment goals, it is possible and often inevitable that the disease will progress. This brings us to our final statement to improve life with diabetes.

The Time2DoMore survey reveals that almost all aspects of clinical inertia in diabetes can be addressed by better communication. We believe that following the simple 4-step pathway and working in partnership with healthcare teams, people with diabetes can improve their quality of life and health outcomes.

Acknowledgements

The authors express their sincere gratitude to all the participants of the survey.

The study was funded by Novartis. WD Strain would like to acknowledge the support of the National Institute for Health Research (NIHR) Exeter Clinical Research Facility and the NIHR Biomedical Research Centre scheme.

Steering Committee:

  • Sir Michael Hirst, International Diabetes Federation
  • Dr David Strain, University of Exeter Medical School, UK
  • Dr Viswanathan Mohan, Dr Mohan’s Diabetes Specialities Centre, India
  • Dr Sérgio Vencio, Catholic University of Goias, Brazil
  • Dr Xavier Cos, Sant Marti de Provençals Primary Care Centres, Spain
  • Dr Daisuke Yabe, Kansai Electric Power Hospital, Japan
  • Dr Zoltán Vokó, Eötvös Loránd University, Hungary
  • Dr Matthias Blüher, Liepzig University, Germany
  • Dr Päivi Paldánius, Novartis Pharma AG, Basel

References

  1. Khunti K, Wolden ML, Thorsted BL, et al. Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people. Diabetes Care 2013; 36: 3411-7.
  2. Strain WD, Cos X, Hirst M, et al. Time to do more: addressing clinical inertia in the management of type 2 diabetes mellitus. Diabetes Res Clin Pract 2014; in press, DOI: 10.1016/j.diabres.2014.05.005

 

David Strain is Doctor at the Department of Diabetes and Vascular Medicine, University of Exeter Medical School, UK.


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