Supporting earlier action in the treatment of Type 2 Diabetes – a call to action
Promoting understanding of the drivers of clinical inertia to support improved outcomes for patients with type 2 diabetes.
Globally 1 in 11 adults currently has diabetes.I The impact of diabetes both on patients’ health and health systems should not be underestimated. Type 2 diabetes costs health systems, on average, 12% of their total expenditure.ii This is set to increase considerably. In 2017, 4 million patients died globally as a result of diabetes and its complications.iii Nearly 650 million people will have diabetes by 2040, and the cost of treating the disease just in adults aged 20-79 years will be $802 billion.iv
With these figures in mind, it is more important than ever that patients receive appropriate treatments at the right time.
Although clinical guidelines have their limitations, it is widely agreed that timely escalation of treatment for type 2 diabetes patients leads to better outcomes for patients and health systems.v
Yet, escalation onto these treatments is not always being seen in clinical practice and patients are therefore not
receiving treatment in line with guidelines.vi,vii
There is evidence that for some patients there is a delay in receiving optimal treatments. In two large scale studies evaluating quality of treatment for patients with type 2 diabetes, GUIDANCE and PANORAMA, only 53.6% and 62.6% of patients respectively achieved recommended HbA1C targets.viii,ix
The consequences of delays to the escalation of treatment can be life- altering for patients and can cause avoidable costs for health systems.x
Delays can lead to suboptimal glycaemic control, poor management of the disease and an increase in comorbidities.xi Poorly controlled diabetes can increase the risk of cardiovascular disease, blindness, kidney failure, amputations and premature death.xii
The decision on whether to escalatea patient’s treatment is complex andmulti-faceted. Multiple considerations are in play from patient, prescriber, health system and payer perspectives.
Drawing on new research, this document explores clinical inertia in type 2 diabetes, identifying areas where action is needed and makes recommendations to support early action in the treatment of type 2 diabetes.
The clinical inertia in primary care project
New evidence, commissioned by AstraZeneca and conducted in partnership with Primary Care Diabetes Europe has been conducted to better understand clinical inertia in type 2 diabetes. The research focussed specifically on aspects of clinical inertia as it relates to the prescribing of first, second or third line type 2 diabetes treatments in accordance with clinical guidelines and sought to understand what
Document Number: Z4-13245 Date of preparation: October 2018 Date of expiry: October 2019
influences treatment decisions among physicians.
Research was conducted in two phases between June and August 2018. The first, qualitative research phase involved 20 in-depth interviews with primary care practitioners (PCPs) in five countries: UK, Spain, Italy, Germany and Poland. The second stage of the research comprised a quantitative study of 600 PCPs in twelve countries: Belgium, Denmark, Germany, Italy, Netherlands, Poland, Portugal, Romania, Spain, Sweden, Switzerland and the United Kingdom. Both stages were double-blinded.
Identifying areas for intervention
Decisions on whether to intensify treatment in type 2 diabetes patients are complex, shaped by multiple considerations, and each may in turn be contributing towards inertia:
Role of clinical guidelines
Clinical guidelines play an important role to determine the treatment decisions of PCPs for their type 2 diabetes patients. Of the PCPs surveyed, 88% said they treated patients according to national and/or local clinical guidelines and 83%believed guidelines could be applied to their diabetes patients.
Although national guidelines are regarded as an important reference by 75% of PCPs to guide treatment decisions, they are not seen as prescriptive, with PCPs using clinical judgement based on patient characteristics and their own experience to drive decision making. When asked which information sources were most important, 67% of PCPs cited clinical judgement, and 55% mentioned recommendations of senior expert colleagues, as influential in their treatment
decisions. Only 23% of PCPs regarded patient preference as important.
When examined further, this qualitative research found that first line treatment is administered in line with guidelines, but as disease progresses and treatment escalates, guidelines are seen to be less prescriptive.
This gives PCPs more flexibility to prescribe and provide individualised care, but it may also be a contributor to variability in prescribing decisions, or delays in uptake.xiii
Although 78% of PCPs believed that early intensification in line with guidelines is associated with clinically relevant benefits, PCPs did not always believe they could prescribe in accordance with the guidelines due to budgetary challenges or complexity of the guidelines themselves.
Recommendations for action
Innovative diabetes treatments must be accessible to all patients who require them. Guidelines should be simplified and aligned with clear recommendations on how and when innovative diabetes treatments should be used.
Organisational and health system factors can also influence the decision to intensify treatments to second and third line therapies, both directly and indirectly.
For 42% of PCPs, time and high patient volumes were seen as influential in guiding the decision to escalate treatment. There is a strong emphasis on engaging with patients to build an efficient relationship to positively influence compliance. However, PCPs acknowledged there is a lack of available time to spend with each patient and believed that increasing the length and frequency of patient consultations would have the greatest impact on patient outcomes.
Cost of treatment also impacted prescribing decisions in a number of ways. For 37% of PCPs, local healthcare systems/insurance companies stipulated that cheaper, older first line therapies should be used in place of innovative treatments. Moreover, almost a quarter (24%) of PCPs believed that there was a lack of reimbursement in order to prescribe novel type 2 diabetes treatment according to guidelines.
Access to resources, including support staff, equipment and a multidisciplinary team also played a role in treatment intensification. For 39% of PCPs, access to a primary care multidisciplinary team (for example in the UK this would include physicians, nurses, podiatrists, dietitians and clinical psychologistsxiv) was seen as a factor influencing intensification to second and third line therapies.
Recommendations for action
Patients and PCPs must get the best out of the time available. To enable this, there needs to be more emphasis on adopting a clinical and support team approach to diabetes management with a coordinated plan for each patient, creating more time for PCPs to focus on determining the best treatment. PCPs also need to feel empowered to prescribe in accordance with the guidelines.
Patient related factors
Patient related factors were often seen as barriers to intensification, most notably lifestyle factors such as smoking, diet, physical inactivity (49%); previous adherence to treatment (45%); and patient comorbidities (42%). Involvement of the patient is considered, as treatment is likely to include lifestyle changes and invasive treatment.
Minimising out of pocket costs for patients was also seen to influence decisions to escalate treatment.
PCPs are often reluctant to prescribe treatments if they believe that the cost of treatment to the patient may limit compliance.
Recommendations for action
Toolkits and face to face support from a primary care multidisciplinary team should be made available to patients to encourage their active involvement in their care and to ensure they are able to make informed decisions about their treatment. To ensure patients have access to information, structured patient adherence/ education programmes, with a focus on the progressive nature of the disease and risks in poor glycaemic control, must be made readily available and actively promoted by PCPs to ensure patients feel empowered to attend.
Clinical inertia is a complex issue. While the challenges of clinical inertia are not unique to type 2 diabetes, the failure to escalate treatments for patients in accordance with clinical guidelines can potentially cause poor outcomes in patients due to undertreatment.
The findings from the survey reflect the real and immediate needs of physicians to determine the best treatment for their patients: simple guidelines that provide clear recommendations on how and when first, second and third line treatments should be used; a team approach to diabetes management that creates more time for PCPs; reimbursement and budgeting policies consistent with the guidelines; and structured patient education endorsed and promoted by PCPs to improve adherence.
While clinical inertia is a common problem across the participating countries, the actions needed to address it may be country-specific, but attention must focus on improving the PCP-patient interaction that lies at the heart of clinical inertia.
i IDF (2017) IDF Diabetes Atlas. Available at: http://www.diabetesatlas.org/
ii International Diabetes Federation, IDF Diabetes Atlas, Seventh Edition, 2015
iii International Diabetes Federation, IDF Diabetes Atlas, Eighth Edition, 2017
iv International Diabetes Federation, IDF Diabetes Atlas, Seventh Edition, 2015
v Pantalone, K. et al. (2018) Clinical inertia in Type 2 Diabetes Management: Evidence From a Large, Real-World Data Set, Diabetes Care
vi Khunti, S. et al. (2015) Clinical inertia in the management of type 2 diabetes mellitus: a focused literature review, Br J Diabetes Vasc Dis, 15: 65-69
vii Khunti, K. et al. (2018) Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review, Diabetes, Obesity and Metabolism, 20:427-437
viii Stone, M. et al. (2013) Quality of Care of People with Type 2 Diabetes in Eight European
Countries – Findings from the Guideline Adherence to Enhance Care (GUIDANCE) study, Diabetes Care, 36(9): 2628-2638
ix Pablos-Velasco, P., et al (2014) Current level of glycaemic control and its associated factors in patients with type 2 diabetes across Europe: data from the PANORAMA study, Clinical Endocrinology, 80(1): 47-56
x Khunti, S. et al. (2015) Clinical inertia in the management of type 2 diabetes mellitus: a focused literature review, Br J Diabetes Vasc Dis, 15: 65-69
xi Khunti, K. et al. (2018) Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review, Diabetes, Obesity and Metabolism, 20:427-437
xii International Diabetes Federation and International Working Group on the Diabetic Foot, Diabetes. Available at:http://www.idf.org/webdata/docs/background_in fo_NA.pdf
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Date of preparation: October 2018
Date of expiry: October 2019
xiii Strain, W. et al. (2014) Clinical inertia in individualising care for diabetes: is there time to do more in type 2 diabetes?, Diabetes therapy, 5(2): 347-354
1: Strain, W. et al. (2014) Clinical inertia in individualising care for diabetes: is there time to do more in type 2 diabetes?, Diabetes Therapy, 5(2):347-354
2: Reach et al. (2017) Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes & Metabolism 43(6): 501-511
xiv Diabetes UK. Specialist diabetes team: role and members. Available at: https://www.diabetes.org.uk/professionals/position -statements-reports/healthcare-professional- staffing-competency/specialist-diabetes-team- role-and-members