In the past 12 years, there has been an 11% decline in the number of Americans with type 2 diabetes who are achieving an A1C less than 7%, and research indicates that one of the major contributors to that trend is therapeutic inertia.
“We know that achieving glycemic control early in the treatment regimen leads to better outcomes because it generates what is known as a legacy effect,” said Christine Beebe, MS, QuantumEd, LLC.
Beebe and Shannon Knapp, BSN, RN, CDCES, Cleveland Clinic, spoke Friday, June 3, during the mini-symposium, Diabetes Care and Education Specialists DCESs Value – Positive Impact of DCESs on Therapeutic Inertia. The session can be viewed on-demand by registered meeting participants at ADA2022.org. If you haven’t registered for the 82nd Scientific Sessions, register today to access the valuable meeting content.
Beebe cited a 10-year follow-up to the UK Prospective Diabetes Study, which determined that patients with type 2 diabetes who had intensive control still had AC1 levels less than 7% and fewer complications than type 2 diabetes patients who received usual care. Another study she cited validated these findings by analyzing data from 21,000 patients with type 2 diabetes over 18 months and looking at those whose providers prescribed intensive therapy in the first six months versus those who did not. Outpatient costs for the latter group were 60% higher than costs for those who received the intensive therapy.
Health economic modeling suggests that the burden of delaying treatment intensification by as little as one year in 13 million or more people with type 2 diabetes who have an A1C above 9% can result in a loss of more than 13,000 life years and more than $7 billion, according to Beebe.
She noted the causes for therapeutic inertia are clinician-, patient-, and systematic-related. Systematic review and meta-analysis indicate that diabetes management programs should be set up to treat patients, taking into consideration different clinician types depending on their settings and who will frequently communicate with the patients. The approaches should also use technology for frequent communication but might not be enough on their own, Beebe said.
“What we need is to empower pharmacists, nurses, diabetes care and education specialists with the autonomy to initiate and intensify treatment, supported by guidelines, protocols, and collaborative agreements, if needed,” she added.
Knapp spoke more specifically about models of care that improve outcomes. She noted that two of the biggest contributors to therapeutic inertia are patient resistance and the way information is conveyed to them.
“We need people to sell our services,” Knapp said. “The provider and diabetes educator relationship is really critical to this. There is a much different message when the physician says, ‘Hey, maybe you should see a diabetes educator,’ versus when he says, ‘Hey, you know, Nancy is one of our diabetes educators, and I think she can really help you. She knows a lot about insulin pumps,’ or ‘She knows a lot about nutrition management. She can really help you to figure out what’s going to work the best for you and tailor things to you.’ That is a much different message, and it will be received a lot better.”
The patient’s entire health care team, including schedulers, the checkout desk, medical assistants, and clinic nurses, should be trained to “sell that service,” Knapp said. Automated processes should also be put in place to match all new type 2 diabetes patients with diabetes educators and to make it easy for the provider and patient to schedule appointments.
Knapp and her colleagues are experimenting with ticket scheduling with exercise physiologists, and the feedback has been positive, she said. As soon as a provider places an order in the patients’ electronic medical records for a consultation with a physiologist, the patients are able to schedule their own appointments and education through the MyChart app. Knapp is hoping ticket scheduling goes live in the next few months for type 2 diabetes patients.
She and her team have also created a boot camp that teaches collaborative care between the primary care physicians, endocrine specialists, pharmacists, and diabetes educators.
Knapp also discussed studies looking at various combinations of health care teams and technology, such as telemedicine, remote monitoring, mobile phone apps, and cloud-based programs, to provide intensive therapy to patients with type 2 diabetes.