Pharmacists, nurses and educators ‘key’ to combating type 2 diabetes therapeutic inertia

Therapeutic inertia is where care stagnates, defined as the failure to establish appropriate targets and escalate treatment to achieve treatment goals.

Researchers from Leicester in the UK and California, Virginia, New Jersey, Utah, Arizona, Texas, Dallas, Ohio and Alabama in the U.S. and the American Diabetes Association® (ADA) Overcoming Therapeutic Inertia initiative led by Professor Kamlesh Khunti investigated the effect of interventions to overcome clinical inertia on glycaemic control in type 2 diabetes, focusing on reduction of HbA1c.

It was the first systematic review on overcoming therapeutic inertia and as well as being published by the Diabetes, Obesity and Metabolism journal, the results were simultaneously shared at the ADA’s virtual 81stScientific Sessions.

“The American Diabetes Association is spearheading an effort to overcome therapeutic inertia to improve the outcomes for all people living with diabetes,” said Dr. Robert Gabbay, Chief Scientific and Medical Officer for the ADA. “This important publication summarizes what works and will help drive improvement in care for generations to come.”

According to the findings: “The most effective approaches to mitigating therapeutic inertia and improving HbA1c were those that empower nonphysician providers such as pharmacists, nurses and diabetes educators to initiate and intensify treatment independently, supported by appropriate guidelines.”

After an extensive trawl of the available published research examining the impact of interventions introduced by different types of healthcare professionals to address therapeutic inertia, 36 studies were included in the review.

The researchers categorised the interventions into the following:

• Pharmacist-based interventions – including medication reviews and make guideline-based adjustments to medications
• Care management and patient education interventions – looking at virtual coaching, or patient education, often supported by remote or telemonitoring
• Physician-based interventions – focused on education in-person, written educational materials.
• Nurse- or CDE-based interventions – using evidence-based protocols to provide diabetes management including treatment initiation or intensification.

A common characteristic of the medication management initiatives led by either nurses, certified diabetes educators (CDE) or pharmacists was their ability to “independently initiate and intensify treatment” as long as they were supported by appropriate guidelines, protocols and collaborative agreements.

Only one of seven physician-based interventions was associated with a significantly greater reduction in mean HbA1c compared to usual care, the study said. However, all of the nurse and CDE-based and pharmacist- based interventions “were effective” at reducing HbA1c, it was concluded.

Summarising the results, the researchers: “Nurse- and CDE-based interventions were associated with greater reductions in HbA1c compared to controls, with a mean HbA1c difference ranging from −17.7 mmol/mol (−1.62%) to −4.4 mmol/mol (−0.40%), while for pharmacist-based interventions reductions ranged from −9.8 mmol/mol (−0.90%) to −6.6 mmol/mol (−0.60%). 

“Corresponding estimates for care management and patient education interventions and for physician-based interventions were −13.1 mmol/mol (−1.20%) to 3.3 mmol/mol (0.30%) and −4.4 mmol/mol (−0.40%) to 2.8 mmol/mol (0.26%), respectively.”

Professor Kamlesh Khunti, who is the Director of NIHR ARC East Midlands and Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester, said: “Despite the availability of effective treatment options and well-established management guidelines, corresponding improvement in reaching glycaemic targets has lagged. 

“The failure of healthcare providers to initiate or intensify treatment when indicated, or to deescalate therapy when appropriate known as therapeutic inertia is a contributing factor to the gap between population health goals for diabetes and current outcomes. That’s why this study is so important because we look how best to address this challenge.”

NIHR ARC East Midlands funds vital work to tackle the region’s health and care priorities by speeding up the adoption of research onto the frontline of health and social care. The organisation puts in place evidence-based innovations which seek to drive up standards of care and save time and money.

To access the study, click here: https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14455.