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Clinical inertia is a significant problem in the treatment of diabetes. That was the emphasis of a media event at the American Diabetes Association's (ADA's) 66th Scientific Sessions, held June 9–13 in Washington, D.C., that highlighted four studies showing that doctors failed to intensify therapy in people with type 2 diabetes and high blood pressure or glucose levels.
"Physicians do not appear to be aware of the ADA guidelines or choose not to follow them," Alexander Turchin, MD, MS, of Brigham and Women's Hospital in Boston, said in a press release.
In a less-publicized symposium on barriers to adherence, researchers provided potential explanations for such clinical inertia to help clinicians understand where they can target interventions to improve diabetes care.
Eve Kerr, MD, MPH, investigator for the Veterans Affairs (VA) Quality Enhancement Research Initiative for diabetes at the VA (Mich.) Ann Arbor Healthcare System, explained clinical inertia as "the failure to initiate or intensify therapy in a defined time among patients who haven't attained clinical goals and whom intensification is likely to benefit."
She notes that apparent inertia can actually be good care in cases where intensification may not be appropriate and that most studies of clinical inertia have not made that clarification.
Other studies have shown that clinical inertia is caused by an overestimation of care provided, a lack of education and training on therapeutic goals, and use of "soft" reasons to avoid intensification (e.g., patient refusal).1
Kerr points to a study of 1,154 VA patients with diabetes that investigated
inertia in diabetic lipid therapy. She says that, although 27% of LDL levels
were 
130 mg/dl, only 13% (148 of 1,154) of patients were classified as
having substandard quality
care.2 But there was
no documented explanation for 113 of those 148 patients.
"This we've termed the `black box' of clinical inertia," she says. "We don't know why nothing was done when it appears something should be done."
To try to open that black box, Kerr and colleagues are studying 92 primary
care physicians at nine VA sites, who care for 1,169 diabetic patients with
blood pressure 140/90 mmHg. The investigators are looking at competing
demands such as comorbidities and differing patient and clinician priorities;
medical factors such as contraindications, side effects, and cost;
measurements such as repeat clinic and/or home blood pressure values;
organization factors such as patient load and whether there is ancillary
support or reminders; and patient-clinician relationship factors including
trust and communication.
The investigators have observed that 24% of the patients had no blood pressure goal, although 47% did receive a therapeutic change to try to control blood pressure.
"We're doing this study to understand where to target intervention to improve blood pressure control," Kerr says. "What happens after the providers make a medical decision? Many steps need to be addressed. It's not just about inertia. Reminders alone won't work to improve blood pressure control unless they include appropriate follow-up care."
Up to 40% of adults with type 2 diabetes are on three or more medications, and 30% take five or more medications, Kerr notes, and providers grapple with time-consuming multiple guidelines and priorities. She suggests that disease management programs might help physicians, but that the solution to clinical inertia may lie in more comprehensive change.
"We need multifaceted approaches that target the provider, patient,
and organization simultaneously," Kerr says. "Essentially, a
system redesign." 
References
2. Kerr EA, Smith DM, Hogan MM, et al.: Building a better quality measure: Are some patients with `poor quality' actually getting good care? Med Care 41:1173–1182, 2003.[Medline]
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