Cross-sectional study looking at the factors leading to therapeutic inertia in the management of T2DM in the UK primary care setting

Azhar Zafar(1,2), Nihad Jalil(3), Arslan Saleem (4), Kamlesh Khunti(1)
1- Diabetes Research Centre, University of Leicester; UK, 2- GP Alliance Federation, Northampton, UK; 3- Northampton General Hospital, UK  4- Hameed Latif Memorial Hospital, Lahore, Pakistan 

Background: Current literature has provided evidence that recommended control of HbA1c, blood pressure, and dyslipidemia reduces the risk of developing diabetes-related macro- and microvascular complications and cardiovascular death(1). Literature presents different factors including clinical inertia, as responsible for these management gaps. Clinical inertia is defined as failure to intensify therapy when indicated (2) and reasons for clinical inertia are multi-factorial (3-4). Current literature cannot demonstrate documented factors leading to clinical inertia in the care of persons living with T2DM in the UK primary care setting (5).  

Aim: To study factors associated with therapeutic inertia in the management of T2DM in the UK primary care setting and to develop a predictor model to estimate the probability of therapeutic inertia based on patient factors, clinical characteristics, and level of care provided. 

Methods: Multicentre, observational, cross-sectional study where each participating clinician-collected clinical data on consecutive patients’ consultations.  An event of therapeutic inertia was defined as a consultation in which treatment change was indicated (i.e. HbA1c > 58 mmol/mol) in all patients but did not occur. The predictive factors were analysed and the association of factors with inertia were validated. 
Results: Data were collected on 128 patient consultations. The binary logistic regression model showed that odds of therapeutic inertia were 1.10 with the increasing age, 38.3 with HbA1c levels of 58-65 mmol/mol as compared to higher HbA1c levels, odds of 6.3 with 66-75 mmol/mol compared to other Hb1A1c levels. Similarly, odds of therapeutic inertia in higher systolic BP (>140) were 1.1. 
The linear regression model predicted (p<0.001) that therapeutic inertia occurred 15.1 times more with lower HbA1c as compared to higher HbA1c (B coefficient 86.57).
Other predictors of therapeutic inertia in consultations included the competing demands of other presenting problems when consulted by GP as compared to a practice nurse (p<0.001) and patient-based factors for clinical inertia.
Conclusion: Although therapeutic inertia is frequent in the management of T2DM, the factors explaining it are not completely clear. Whereas some aspects of the consultations were associated with therapeutic inertia, patient-related factors were not the only decisive factor leading to clinical inertia.

Cross sectional study to look at the factors leading to clinical inertia in UK primary setting in the management of T2DM