Aims: Failure to intensify therapy, which is an error of omission, is a leading cause of failure to reach evidence-based diabetes care goals. In this report we quantify provider, care system, and patient reasons for failure to appropriately intensify glucose medications.
Methods: As part of a larger study, 19 primary care physicians using an EMR-based clinical decision support tool completed a visit action resolution (VAR) form at each visit involving selection from a checklist of possible reasons why diabetes treatment was not intensified at office visits when patients with diabetes were not at recommended clinical goals.
Results: EMR decision support was used and VAR completed at 831 of 1639 (51%) visits with elevated glycated hemoglobin (A1c >= 7%); glucose medications were not intensified at 258 (43%) of the 831 VAR completed visits. Physician-identified reasons for no treatment intensification were: (1) Patient choice or preference, 70 (19.6%), (2) Need for updated A1c, 62 (17.3%), (3) Patient of endocrinology or diabetes nurse, 53 (14.8%), (4) Addressed dietary/lifestyle changes instead, 45 (12.6%) (5) Competing clinical demands, 17 (4.7%), (6) Not my patient, 13 (3.6%) (7) Addressed adherence problem, 13 (3.6%). Less frequently cited (< 2.5%) were medication regimen already too complex, hypoglycemia concerns, drug intolerance, cost concerns, advanced age or severe co-morbidities, referred to endocrinology or diabetes educator, close to goal, and other.
Conclusions: We conclude that less than 20%, of clinical inertia is attributable to patient refusal or preference. A majority of instances of clinical inertia could potentially be addressed through provider training or care system changes such as point of care A1c testing and better coordination of care with subspecialty and primary care colleagues.