Vol. 15 •Issue 4
• Page 69
Overcoming Clinical Inertia In Diabetes Care
Point-of-Care A1C Testing a Valuable Tool
By Debbie Hinnen, NP, CDE, and Virginia Valentine, CNS, CDE
"My blood sugars are high, but nobody does anything. My doctor says, 'Let's watch things for 3 months and see if they improve.'"
These comments typify widespread clinical inertia in diabetes management today. This wait-and-see approach is frustrating to many patients – not to mention detrimental to their health.
New medications are available to treat diabetes more effectively. Technologies for glucose self-monitoring, A1C testing and glucose data analysis have improved in complexity and capability. National organizations have set standards for monitoring diabetes-related risk factors. Insurance companies and other entities are even rewarding providers based on how well they monitor diabetes risk factors. Given all these tools, diabetes should be a well-managed disease in this country. It is not.
Yes, providers are monitoring glycemic targets and risk factors. But national monitoring programs such as the Behavioral Risk Factor Surveillance System and the National Health and Nutrition Examination Survey (NHANES) report that diabetes control has not improved significantly in the past 15 years. Fewer than 10% of people with type 2 diabetes are winning the trifecta of diabetes: management of glucose, hypertension and elevated lipids.1
Clinical inertia is rampant. Health care providers are monitoring glucose and discovering that patients are not at target, yet they do nothing to intensify therapies.2-4 Less than half (42.9%) of patients with diabetes are meeting glycemic guidelines established by the American Diabetes Association (ADA) or the American Association of Clinical Endocrinologists (AACE).5
To examine this clinical inertia, a research team compared A1C levels and therapy intensification within the primary care and diabetes clinics of an urban academic center.3 They found that patients treated in the primary care center had higher A1C levels, lower insulin treatment rates and less frequent intensification of therapy.3
Other investigators have discovered that clinical inertia is not limited to the primary care arena: It exists in endocrine and diabetes specialty clinics as well. A review of quality diabetes measures in 30 academic institutions, including patient records from general medicine and endocrinology, found that only 34% of patients in either setting were at goal (defined as A1C ²7.0%).4 The researchers also documented low rates of pharmacologic therapy and therapy adjustment in patients who exceeded goal.4
Clearly, this is a problem for all of us — and one that requires our immediate and devoted attention.
Advances in Monitoring
Today's patients are well equipped to monitor and manage their diabetes. Diabetes is a game of numbers. So much so that "Know Your Numbers" is the name of a national campaign to help people recognize whether they have achieved their targets for control.6
Glucose monitoring is the primary tool for monitoring blood sugar control. Testing techniques have never been simpler, and meter calibration has become nearly automatic. Only a miniscule (0.3 mL to 0.6 mL) blood sample is required, making this alternate site testing possible. In addition to the fingers, the forearms and the heels of the hands or legs can be lanced to obtain blood samples.
Meters now interface with home computer systems to download and organize data. Patients can more easily perform pattern management by studying glucose levels from specific times of the day. This ability to analyze and react to food, exercise or medication changes helps patients combat clinical inertia themselves.7
Some of today's glucose monitors transmit glucose values directly to insulin pumps via radio frequency or infrared technology. This link enhances ease of use and convenience. And continuous glucose monitoring is emerging with the same capability to "speak" directly to insulin pumps.
Critical for Disease Management
Glucose monitoring frequency has been well studied among people on insulin and is recommended four times per day, every day. In type 2 diabetes, the frequency required to assist with glycemic control is less clear. Educators and providers understand the need for monitoring, the educational value of testing after eating certain foods, the need for testing before and after exercise, and the necessity for data when oral medication titration is undertaken.
In a recent review of national data, researchers noted a correlation between increased self-monitoring and increased access to diabetes educators.8 Glucose monitoring can help quantify hypoglycemia, document treatment progress and assure safety before operating heavy machinery. These capabilities make a strong case for self-monitoring in people with type 2 diabetes who take oral agents. Recommendations about glucose monitoring frequency for type 2 diabetes range from once or twice every day to four times per day 3 or 4 days per week. Patients doing self-management and providers who plan clinical management need data to represent each meal and medication time and action. Spotty data do not provide enough information to perform adequate pattern management.
Testimony at a recent public meeting, sponsored by the Centers for Medicare and Medicaid Services to hear comments about glucose monitoring, challenged the benefit of self-monitoring for all patients with type 2 diabetes.9 Other authors have made observational assessments about the frequency of glucose monitoring and A1C testing, concluding that the link between self-monitoring frequency and improvements in A1C is limited.10
Health care providers would likely concur. Testing alone doesn't improve A1C levels. Glucose monitoring must be accompanied by education and problem solving. Without adequate education, no one knows what to do with the numbers. Not taking action when glucose levels and A1C levels are elevated allows glycemic control to further deteriorate and clinical inertia to entrench itself into clinical practice. The answer is not to eliminate glucose monitoring, but to provide better tools and educational strategies.
Glycated Hemoglobin
The Diabetes Control and Complications Trial provided clear indications of the link between A1C and the development of long-term complications associated with diabetes.1 And the United Kingdom Prospective Diabetes Study proved that this link exists in type 2 diabetes. Although A1C is clearly a major indicator of glycemic control, it is woefully underused.1
In addition to underuse, a lack of understanding is common. Patients who undergo A1C testing often don't know their most recent A1C result or when it last was measured.11 An AACE survey of more than 157,000 diabetes patients determined that 61% did not know what an A1C test was, and 51% did not know their last A1C result. Eighty-four percent said their glycemic control was well-managed when, in fact, the survey indicated that two of every three patients failed to meet AACE's A1C goal of 6.5% or less.12 A review of NHANES data analyzed progress toward target A1C by therapy type and concluded that just under half of patients are achieving a target A1C of <7.0%.1,13
Due to clinical inertia, even patients who continue to miss important A1C targets do not experience any change in therapy. Treatment algorithms and care standards indicate how and when more intensified therapy should be administered, but widespread application of these algorithms is not occurring within recommended periods of time. New efforts include a recently published algorithm for type 2 diabetes, developed by the ADA and the European Association for the Study of Diabetes, which calls for earlier, more aggressive therapy.14
Point-of-Care A1C
Conventional A1C is measured in the clinical laboratory and thus requires patients to visit the lab before or after the clinical interaction. Many patients miss or ignore these lab appointments. A lack of A1C data limits the provider's ability to appropriately explore factors that may be affecting A1C. It also limits the provider's ability to educate patients about the role pharmacologic therapy plays in A1C and improved glycemic control.
A number of A1C analyzers now allow for testing at the point of care (POC), be it in the office or the office laboratory. Obtaining a current A1C result during the clinical interaction allows the provider to clarify the relationships between therapy and blood glucose and lifestyle and blood glucose. In addition, experts believe that POC results are more likely to lead to appropriate intensification of therapy.
A controlled, randomized trial involving 201 diabetes patients documented an increase in daily injections and improved glycemic control in patients who received A1C testing at the point of care vs. those tested in the clinical laboratory.15 A prospective study of 597 patients found that providers intensified treatment in 51% of the POC group vs. 32% of the clinical laboratory group.16 Other research has produced similar results.17 For this reason, the ADA now recommends POC testing for A1C to allow for timely decisions about therapy changes, when needed.18
Putting It Into Practice
As certified diabetes educators and experienced providers of diabetes care, we concur with the ADA in recommending that providers incorporate a point-of-care A1C test as a tool to reduce clinical inertia. The results of POC testing can be used as an important teaching tool and systematic method for engaging patients in their diabetes control.
Despite advances in glycemic testing and diabetes therapies, clinical inertia is a reality. We can improve this situation by encouraging our patients to monitor their glucose and recognize its relationship to daily activities — after we have provided the education necessary for them to do so.
In addition, we must familiarize ourselves with and rely on new treatment algorithms and optimize the teachable moments available through the use of A1C point-of-care testing technologies. Good glycemic control is in our hands.
References
1. Koro CE, et al. Glycemic control from 1988 to 2000 among U.S. adults diagnosed with type 2 diabetes. Diabetes Care. 2004;27(1):17-20.
2. Phillips LS, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825-834.
3. Ziemer DC, et al. Clinical inertia contributes to poor diabetes control in a primary care setting. Diabetes Educator. 2005;31(4):564-571.
4. Grant RW, et al. Quality of diabetes care in U.S. academic medical centers. Low rates of medical regimen change. Diabetes Care. 2005;28(2):337-342.
5. Saaddine JB, et al. A diabetes report card for the United States: quality of care in the 1990s. Ann Intern Med. 2002;136(8):565-574.
6. Know your diabetes ABCs. National Diabetes Education Program. Available at: http:/www.ndep.nih.gov/diabetes/control/4steps.htm#2. Accessed Jan. 29, 2007.
7. Hinnen DA, et al. Combating clinical inertia with pattern management. In: Mensing C, ed. The Art and Science of Diabetes Self-Management: A Desk Reference for Healthcare Professionals. Chicago IL; AADE; 2006: 357-370.
8. Saaddine JB, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002. Ann Intern Med. 2006;144(7):465-474.
9. Medicare Coverage Advisory Committee (MCAC). Medicare coverage database, glycemic control. Available at: http://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=36. Accessed Jan. 8, 2007.
10. Davis WA, et al. Is self-monitoring of blood glucose appropriate for all type 2 diabetic patients? The Fremantle Diabetes Study. Diabetes Care. 2006;29(8):1764-1770.
11. Delamater AM. Clinical use of hemoglobin A1c to improve diabetes management. Clinical Diabetes. 2006;24:6-8.
12. American Association of Clinical Endocrinologists. State of diabetes in America: a new report reveals America's diabetes health is in jeopardy. Available at: http://www.aace.com/public/awareness/stateofdiabetes/DiabetesAmericapressrelease.pdf. Accessed Jan. 10, 2007.
13. Resnick HE, et al. Achievement of American Diabetes Association Clinical Practice Recommendations among U.S. adults with diabetes, 1999-2002. Diabetes Care. 2006;29(3):531-537.
14. Nathan DM, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care. 2006; 29(8):1963-1972.
15. Cagliero E, et al. Immediate feedback of HbA1c levels improves control in type 1 and insulin-treated type 2 diabetic patients. Diabetes Care. 1999;22(11):1785-1789.
16. Miller CD, et al. Rapid A1c availability improves clinical decision-making in an urban primary care clinic. Diabetes Care. 2003;26(4):1158-1163.
17. Unger J. Targeting glycemic control in the primary care setting. The Female Patient. 2003;28(9):1-4.
18. Standards of Medical Care in Diabetes — 2006. American Diabetes Association. Diabetes Care. 2006;29(Suppl 1):S4-S42.
Debbie Hinnen is a nurse practitioner, certified advanced diabetes manager and certified diabetes educator. She is the education coordinator for Mid-America Diabetes Associates of Wichita, Kan., and is a past president of the American Association of Diabetes Educators. Virginia Valentine is a clinical nurse specialist, certified advanced diabetes manager and certified diabetes educator who is chief operating officer of Diabetes Network in Albuquerque, a disease management company focused on diabetes.
Diabetes: The Scope of the Problem
A synopsis from the American Diabetes Association (www.diabetes.org)
Total: In the United States, 20.8 million children and adults have diabetes. That number represents 7% of the population.
Diagnosed: 14.6 million people
Undiagnosed: 6.2 million people
Younger than 20 years old: 176,500, or 0.22% of all people in this age group, have diabetes. About 1 in every 400 to 600 children and adolescents has type 1 diabetes.
Young adults: 20.6 million (9.6%) of U.S. residents ages 20 or younger have diabetes.
Older adults: 10.3 million (20.9%) of U.S. residents ages 60 or older have diabetes.
Men: 10.9 million (10.5%) of U.S. men 20 or older have diabetes — but nearly one-third do not know it.
Women: 9.7 million (8.8%) of U.S. women 20 or older have diabetes — nearly one-third do not know it. The prevalence of diabetes is at least two to four times higher among women of non-Hispanic black, Hispanic, Latino, American Indian, and Asian or Pacific Islander heritage than among non-Hispanic white women.
Non-Hispanic whites: 13.1 million (8.7%) of non-Hispanic white U.S. residents 20 or older have diabetes.
Non-Hispanic blacks: 3.2 million (13.3%) of non-Hispanic black U.S. residents 20 or older have diabetes. After adjusting for population age differences, non-Hispanic blacks are 1.8 times as likely to have diabetes as non-Hispanic whites.
Hispanic and Latin Americans: After adjusting for population age differences, Mexican Americans, the largest Hispanic and Latino subgroup, are 1.7 times as likely to have diabetes as non-Hispanic whites.
American Indians and Alaska Natives: 99,500 (12.8%) of American Indians and Alaska Natives 20 or older who received care from the Indian Health Service in 2003 had diagnosed diabetes. One hundred eighteen thousand (15.1%) American Indians and Alaska Natives 20 or older have diabetes (diagnosed and undiagnosed). Taking into account population age differences, American Indians and Alaska Natives are 2.2 times as likely to have diabetes as non-Hispanic whites.
Asian Americans and Pacific Islanders: The total prevalence of diabetes (diagnosed and undiagnosed) is not available for Asian Americans or Pacific Islanders. However, in Hawaii, Asians, Native Hawaiians and other Pacific Islanders 20 or older are more than twice as likely to have diagnosed diabetes as whites, after adjusting for population age differences. Similarly, in California, Asians are 1.5 times as likely to have diagnosed diabetes as non-Hispanic whites.
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