Clinical inertia in the management of Type 2 diabetes metabolic risk factors

Aims Delays in the initiation and intensification of medical therapy may be one reason patients with diabetes do not reach evidence-based goals for metabolic control. We assessed intensification of medical therapy over time, comparing the management of hyperglycaemia, hypertension, and hyperlipidaemia. Methods Prospective cohort study of 598 adults with Type 2 diabetes receiving primary care in an academic medical centre from May 1997 to April 1999. We assessed whether patients failing to achieve standard treatment goals for haemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), or low density lipoprotein (LDL) cholesterol when last measured during 12 months (Year 1, 5/97-4/98) had increases in their corresponding medical regimen during the following 12 months (Year 2, 5/98-4/99). Results Among untreated patients in Year 1, seven of 12 (58%) of those above goal for HbA(1c) were initiated on medical therapy in Year 2, compared with 16 of 48 (34%) above SBP goal (P = 0.02) and 26 of 115 (23%) above LDL cholesterol goal (P = 0.02). Among patients on therapy and above goal, 124 of 244 (51%) patients with elevated HbA(1c) had their regimen increased in Year 2, compared with 85 of 282 (30%) with elevated SBP (P < 0.001) and 22 of 79 (30%) with elevated LDL cholesterol (P < 0.001). From Year 1 to Year 2 there was a decline in the overall proportion of patients above goal for LDL cholesterol (from 58% to 45%, P = 0.002) but not for HbA(1c) or blood pressure. Conclusions Greater initiation and intensification of pharmaceutical therapy, particularly for elevated blood pressure or cholesterol, may represent a specific opportunity to improve metabolic control in Type 2 diabetes.