Factors associated with Clinical Inertia in achieving optimal glycemic control in South Asia: The CARRS Trial
Background
Failing to achieve optimal glycemic control (HbA1c levels <7%) has been associated with an increased risk of long-term complications among people with type 2 Diabetes Mellitus (T2DM). Diabetes patients often exceed desired HbA1C levels for months prior to medication adjustments. Clinical inertia (CI) in T2DM care is characterized by a failure to intensify therapy despite inadequate treatment response and glycemic control. There is limited documentation of CI patterns in patients with sub-optimal glycemic control in South Asia.
Aims
We investigated the prevalence of and factors associated with clinical inertia in diabetes management in South Asia using data from the CARRS (Centre for Cardiometabolic Risk Reduction in South Asia) Trial.
Methods
We analyzed data from the intervention arm of a large pragmatic randomized controlled Trial (CARRS Trial) in which 1146 T2DM patients, with glycated hemoglobin (HbA1C) ≥8% and either: systolic blood pressure (SBP)≥140mmHg or low-density lipoprotein cholesterol (LDLc)≥130 mg/dl were randomized between March 2011 – August 2012 to receive the multi-component intervention consisting of non-physician care coordinator (to facilitate patient care) and clinical decision support software [DSS] (to enhance physician responsiveness) (n=575) or usual care (n=571). Based on current HbA1c, fasting and post-prandial blood glucose values and medications, treating physicians were provided with DSS glycemic prompts for up-titration if the patient was not achieving the target HbA1c<7%. Data were extracted for clinic visits at: 6 month, 12month, and 24month. CI was defined as failure to intensify treatment with ≥ 1 additional Oral Anti-Diabetics (OAD), or insulin or increasing the dose of currently prescribed OAD/insulin during the response period of 3 or 6 months (and rejection of DSS glycemic prompts). Concurrent to intervention implementation, 35 in-depth physician interviews were conducted at baseline, interim, and end of study. Physicians were asked about their experiences integrating the intervention components into their usual care practice, with a focus on the rationale behind DSS prompt acceptance and rejection. Interview data were deductively coded for acceptability of DSS prompts and perspectives on achieving glycemic control, and thematically analyzed.
Results
The prevalence of CI was 39%, 44%, and 42% at 6month, 12month, and 24months of follow-up (Table 1). Patients aged 50-64 years, with secondary school education, homemakers, low-income group (INR <10000), those who had more hospitalizations, and neuropathy had higher prevalence of CI. Patients with lower levels of CI tended to have diabetic retinopathy, nephropathy, higher diabetes disease duration, higher co-morbidities, and history of cardiovascular disease (p<0.01). Physicians provided several reasons why the DSS glycemic prompts may have been rejected: (1) the recommended increase in dosage was too aggressive, (2) patient’s non-adherence to previously prescribed medication, (3) lack of sufficient time to see improvements from lifestyle modifications. Several physicians also stated that patient characteristics affect their approach to achieving glycemic targets, most notably that they are stricter with younger patients when it comes to adhering to the target guidelines.
Discussion
These findings provide preliminary insight into patterns among T2DM patients who experience CI. The observed proportion of CI in this study was significantly lower than in US managed care settings (42% vs. 72.8%). The identified factors provide a starting point for future research and to better understand CI, future research should focus on understanding how provider’s decision-making in response to poor glycemic control is influenced by individual patient characteristics, needs, beliefs and attitudes.

Factors associated with clinical inertia in achieving optimal glycemic control in South Asia: The CARRS Trial