TABLE 1

Potentially Useful Approaches to Overcome Therapeutic Inertia in Type 2 Diabetes

ApproachWhat to DoEvidence/Examples
Provider educationEnhance providers’ medical knowledge on diabetes and its treatment, including:Redesign professional health education to adapt professional competencies to specific contexts (58) (e.g., teaching about ethics and social science as part of the undergraduate/ graduate medical curriculum to convince providers of the benefit of applying rules of best practice and of their importance as health care providers (41).
• The natural history of the disease, from correcting modifiable risk factors to drug treatment and further need for titration
• The evidence coming from guidelines
• How to use clinical guidelines
• The reasons behind therapeutic decisions and appropriate selection of medications
• The appropriateness of guidelines for each particular patient
• The phenomenon of lack of patient engagement and therapeutic inertia
Promote continuing medical education throughout professional life.Educational meetings and interactive workshops improve professional practice and health care outcomes for patients (59,60). Simulated case-management interventions have also been shown to improve the diabetes management skills, knowledge, and confidence of primary care residents (61).
Use reminders (e.g., in the form of an electronic spreadsheet) and feedback systems (e.g., regarding patients’ treatment target attainment).Reminders and feedback have been shown to improve physicians’ use of clinical practice guidelines and ability to overcome therapeutic inertia in diabetes and hypertension (62).
FacilitationSimplify treatments and/or use medications with fewer side effects.Complex treatments lower patient engagement (63), and fear of side effects can lead to less medication taken and to providers’ therapeutic inertia. The use of medications with fewer side effects or using combined forms of medications may reduce therapeutic inertia and improve treatment success (64,65). The use of improved insulin delivery devices helps to reduce patient nonadherence (66).
Use protocols and algorithms to reduce decision uncertainty.Giving simple algorithms of titration to providers has a positive effect on treatment intensification and improves glucose and blood pressure levels (67). The use of computer-assisted decision support in primary care is effective in improving the management of type 2 diabetes (68).
Use electronic medical records.The use of electronic medical records and implementation of electronic reminders help in monitoring patients and have a positive effect on quality of diabetes care (6973).
Implement disease management programs.Disease management programs or structured treatment plans help patients better manage their disease and maintain and improve quality of life (e.g., including medication and other treatments, training courses, and regular checkups). Implementation of disease management programs in diabetes has shown improvements in glycemic levels, screening rates, and engagement (7476).
Establish coordinated health care plans aligned with policy initiatives to increase the accountability and patient-centeredness of disease management.Disease management at the population level has significant potential for improving diabetes care and outcomes, but published evaluations of specific diabetes population care approaches are scarce (77,78).
Overcome providers’ lack of time through health information technologies (telemedicine).Compared with standard care, the addition of health information technologies, and in particular mobile phone–based approaches and systems that allow medication adjustments, is an effective tool for glycemic management among people with type 2 diabetes (79,80).
Increase sharing of patient data among health care professionals.Improved access to patient data among health care professionals, combined with data-sharing agreements, may facilitate timely intensification by primary care providers and therefore improved glycemic levels in type 2 diabetes (81).
Reinforcement of health professionalsProvide incentives from health authorities (i.e., pay-for-performance models) to motivate providers to improve their practices.There is evidence of improvement in achieving A1C targets using financial incentives to primary care physicians in the United Kingdom, although the evidence is limited in other countries and the effect is variable (82,83). In the United States, financial incentives improved glucose monitoring during the incentive period but did not significantly improve glycemic levels among adolescents and young adults with type 1 diabetes (84).
Provide incentives from peers.Communication and collaboration between diabetologists and primary care providers is important to overcome therapeutic inertia (85). Concurrent visit reviews with peers have been shown to increase intensification rates (86).
Provide incentives by other health care professionals (e.g., pharmacists and nurses)A study in the Netherlands showed that therapeutic inertia was less frequent when physicians were assisted by a nurse (87). Collaboration between physicians and pharmacists has been shown to decrease clinical inertia scores for blood pressure treatment (88).
Reinforcement of patientsDevelop shared treatment decision-making between providers and patients in a patient-centered approach.Shared decision-making in type 2 diabetes has been reported to improve engagement with health care recommendations and glycemic levels (89,90).
Encourage patients through structured self-management education (e.g., on side effects, managing injections, and insulin dose adjustments).Providing patients with the ability and skills necessary for proper diabetes management determines treatment satisfaction and is effective at improving aspects of diabetes care (91,92). Remote type 2 diabetes care (nurse-led online management program) can facilitate glycemic control compared with usual care (93).
Remove financial barriers and reduce patients’ out-of-pocket costs.High out-of-pocket costs are a barrier to self-management and result in increased likelihood of elevated glycemic levels and intermediate outcomes and lower engagement with regard to diabetes medications (94).
Address psychosocial issues.Increasing patients’ perceptions about their own abilities and self-efficacy is an important factor related to improved diabetes self-management and treatment outcomes (94). Psychological barriers such as inadequate family or social support, misinformation or inaccurate beliefs about illness and treatment, emotional distress or depression symptoms, or deficits in problem-solving or coping skills are associated with lower adherence to diabetes medications (95). Intensive psychosocial interventions are associated with significant reductions in both diabetes distress and A1C in patients with elevated glucose levels and at least one risk factor for poor outcomes (96).