Overcoming Clinical Inertia in the Management of Type 2 Diabetes

Diabetes is a disease associated with significant, life threatening complications. Adequate glycemic control is essential to prevent micro- and macrovascular complications. Despite the wide dissemination of published evidence and clinical guidelines, fewer than half of individuals with diabetes achieve glycemic control. Providers contribute to this problem by not initiating or intensifying therapy when warranted. Clinical inertia, which is recognizing a clinical problem but failing to act on it, is a significant contributor to uncontrolled hyperglycemia in the care of patients with type 2 diabetes (T2DM). Causes of clinical inertia include lack of knowledge or experience with insulin management and poor appreciation for the progressive nature of diabetes. Knowledge building tools such as algorithms are effective means of overcoming clinical inertia in healthcare providers. Algorithms increase knowledge, are convenient, and are effective for communicating clinical pathways for intensification of diabetes therapy. A clinical diabetes treatment algorithm was created for the Hope Clinic, a free medical facility for uninsured and underserved patients, to address clinical inertia in diabetes care at the clinic. The aim of this project was to improve clinical management of patients with T2DM at the Hope Clinic. Specific objectives of this project were to: (1) identify barriers related to the implementation of evidence-based treatment guidelines for T2DM, (2) construct a diabetes clinical pathway algorithm that incorporates current evidence of diabetes care best practices in therapy intensification for patients whose hyperglycemia is not currently being controlled based on American Diabetes Association (ADA) guidelines, (3) improve the consistency of providers' management of patients with T2DM and their adherence to published diabetes management guidelines, (4) increase number of insulin initiations among patients who meet criteria for insulin therapy, and (5) communicate these findings via a professional nursing forum. Pre- and post-evaluation chart reviews were performed to determine the extent of the problem and to evaluate clinical practices pre- and post-implementation. With use of the algorithm, appropriate initiation and intensification of diabetes therapy increased from 58% to 87%. The rate of insulin initiations also increased from 33% to 91%. Appropriate treatment of pre-diabetes improved from 33% to 83%. Given that intensification of therapy improves uncontrolled hyperglycemia, continued use of the algorithm should improve long-term clinical outcomes in patients with T2DM. However, long term evaluation of patient outcomes and providers diabetes management practices is imperative to evaluate both the effectiveness and sustainability of the algorithm.