Conquering diabetes therapeutic inertia: practical tips for primary care

Empower patients

The following approaches can be utilized to empower patients:

1. Make diabetes the priority of the visit. When scheduling appointments, identify at least one appointment every year as being specific to their diabetes management [14]. A diabetes-focused appointment conveys the importance that you and your staff are placing on facilitating optimal diabetes management with the patient. It allows the time needed to better identify and address the concerns and barriers patients may have that are interfering with their ability to optimally participate in the self-management of diabetes. These appointments also foster a trusting patient/physician relationship that is critical to shared decision making and patient-centered care.

2. Utilize shared decision making to set and track targets and time frames. Creating personalized goals that incorporate cultural and personal preferences is important to obtain acceptance and willingness from the patient for optimizing glucose levels [15]. In addition, creating a realistic timeframe for obtaining these goals is important for the positive legacy effect [10].

3. Integrate screening for social or emotional barriers and identify support. Upon identification of these patients with suboptimal glycemic levels, physicians should reach out and attempt to discern if there are any barriers impacting the ability to keep appointments. Social determinants of health affect the ability for patients to make and keep appointments. Issues surrounding cost, transportation, day care, and time off from work can all affect the ability to seek care [16]. Additionally, psychosocial considerations including diabetes distress, depression, and anxiety can impact the achievement of glycemic goals [17]. In addition, diabetes literacy, numeracy, and food insecurity can impact the achievement of glycemic goals and should also be assessed [18, 19]. The ADA’s Overcoming Therapeutic Inertia initiative recommends leveraging support staff, locating support services, and making referrals to help patients overcome any barriers [20].

4. Utilize thoughtful prescribing. The choice to take medication can be impacted by many factors including cost, fear of injection, and personal preference [10, 17]. The ADA’s algorithm for medication selection considers cost as a major barrier for people with diabetes and offers recommendations to help mitigate cost [21]. As previously mentioned, shared decision making is central to the Overcoming Therapeutic Inertia initiative.

5. Refer to diabetes self-management education and support (DSMES) services. Equate DSMES and medical nutrition therapy (MNT) to be as important as medication therapy and refer your patients. Too often, busy physicians treat diabetes alone and do not utilize the additional resources that can help our patients. Just as physicians require ongoing continuing education to remain current on the management of illness, health, and wellness, it is equally important for patients to be knowledgeable about the management of diabetes. Encourage your patients to attend diabetes self-management education (DSME) when initially diagnosed, with changes in their therapy, when their health status changes, and at least once yearly for annual assessment [22].

Optimize care and treatment

1. Conduct practice-based screening for likely TI. Two systematic reviews [23, 24] demonstrated that organization-directed workplace interventions that improve processes, optimize electronic health records (EHRs), and implement team-based care can optimize the coordination and communication of patient care and health information. Another way to optimize your EHR is to utilize the data-mining ability available literally at your fingertips [25]. Periodically, and at least once a year, you should access the EHR to identify patients that are at risk for or are potentially experiencing TI. This would include patients who have not had a visit in at least 6 months and/or have an A_1c above target such as over 8.0%. In addition, many EHRs can assign patient-related tasks to specific members of the healthcare team and can therefore track the progress of accomplishing them. In doing so, this enhances the accountability of all staff members and reduces the possibility that something may be overlooked.

2. Utilize personalized diabetes care plans. Employ motivational interviewing with your patients. At the beginning of every visit, you should ask open-ended questions that will prompt your patient to identify their successes, challenges, and concerns. This will allow the patient to help set the agenda for the visit and be engaged during the appointment [26]. After setting goals, you should continue to utilize shared decision making to create care plans that consider cultural and personal preferences, the impact of social determinants of health, and psychosocial needs [20].

3. Utilize a team-approach to increase the frequency and quality of engagement. There is good evidence that an increased number of touchpoints can help people improve glucose control [15]. There are many other people who can assist in care, and those individuals vary based on what is available in your area. Team members could include the primary care clinician, health educator, diabetes care and education specialist (DCES), clinical pharmacist, community health worker, mental health specialist, and registered dietician/nutritionist (RDN). The Beyond Type 2 diabetes website provides a tool that can help people find the closest certified DCES [27]. Other team members may include family and friends, co-workers, support groups, religious leaders, and online coaches [17, 28]. Helping the patient find the best team for them is an important task that should not be overlooked.

A recent meta-analysis of 36 studies (n=22,243) reviewed the effect of nonphysician providers including nurses, pharmacists, and certified diabetes educators as agents to overcome TI. These interventions resulted in improvement in HbA_1c, and they often exceeded the benefit from physician interventions [29]. The authors concluded that levering these nonphysician providers to intensity treatment utilizing the appropriate guidelines can overcome TI. Integrating clinical pharmacists into your patient’s care can provide critical information about diabetes medications and how to optimize the medication regimen in chronic conditions via medication therapeutic management (MTM) [30]. This is a covered benefit for many insurances and has been shown to reduce polypharmacy and improve patient safety. In addition, RDNs should also be included in the treatment team, because nutrition is the foundation of diabetes treatment. Because nutrition therapy is a covered benefit (as much as four or more times annually), RDNs should be engaged to help achieve glycemic targets.

Within your own office setting, a coordinated team approach is critical. Some ways to optimize your office include empowering medical assistants (MAs), nurses, and even students. MAs can be trained in motivational interviewing and the basics of diabetes care management to enable them to act as diabetes health coaches. Patients receiving care in primary care clinics utilizing MAs as health coaches showed significant improvement in A_1c and cholesterol levels when compared to usual care [31]. In this study, coached patients achieved the HbA_1c almost twice as often as noncoached patients (48.6 vs. 27.6%, p=0.01). Both quality of care and patient satisfaction were also increased when patients received health coaching [32]. This is especially true for patients who do not speak English [32]. MAs are often racially, ethnically, and linguistically concordant with the patient population compared to HCPs [33]. For example, Spanish-speaking MAs can overcome cultural and language barriers with Spanish-speaking patients through health coaching.

Another way to include your MA as part of the team is to have them reach out to patients 1 or 2 weeks after the appointment to ascertain questions or concerns. Engaging MAs in this fashion helps integrate them as members of the diabetes care team. The authors report that they receive anecdotal feedback from their staff that they believe that they are recognized as integral members of the team. They are also able to develop a trusting rapport with the patient that not only reduces delays in care but also improves patient satisfaction. When our patients are more engaged, they are provided an opportunity to self-advocate and report that they feel genuinely cared about by the entire office staff.

In addition, students can be especially valuable in creating and optimizing your team [34]. For example, you can train MA, nurse practitioner, or physician assistant students to assist in insulin titration and hypoglycemia management. This can be an affordable way for preceptors to implement a team-based approach for practices that would otherwise lack the personnel or resources to do so.

1. Utilize A_1c and glucose data to drive rapid-cycle treatment intensification. The ADA Overcoming Therapeutic Inertia initiative recommends utilizing a combination of point-of-care A_1c testing, continuous glucose monitors, and/or self-monitoring of blood glucose data to intensify approaches [20].

2. Stratify follow-up based on A_1c/glucose and therapy change. Before a patient even leaves the office, you should schedule their follow-up visit. How soon the follow-up visit should occur should be based upon the following: (1) treatment change and how soon the earliest maximal impact is expected; (2) the side-effect profile that may impact adherence; (3) the level of complexity (injectable, timing, etc.); (4) the stability levels of current glycemic patterns from self-monitoring or continuous glucose monitoring; and (5) the need to follow up on outcomes of referrals to specialty care or DSME. Table 1 demonstrates recommendations for follow-up based on A_1c parameters [20]. Prior to the leaving the office, the patient should be provided a printout that includes a summary of the visit and what needs to be done prior to the next appointment (lab orders, referrals, etc.) as well as what the patient should bring to the next appointment (blood glucose monitoring devices, nutritional/physical activity logs, etc.).

Leverage technology and tools

1. Adopt a diabetes algorithm. The ADA “Standards of Medical Care in Diabetes” (Standards of Care) is a great place to start for creating diabetes algorithms for all physicians, nurse practitioners, and physician assistants in your practice [21]. In addition, you should create protocols for nursing and MA staff that can streamline care and ensure that all patients being seen for diabetes management receive the same level of care. An example could be that any patient found to have their most recent A_1c over 3 months ago would automatically receive a point-of-care test by the MA prior to being seen. Other protocols could include vaccinations (e.g., influenza, pneumococcal), yearly dilated eye exam referrals, DSME referrals, and identification of annual screening labs such as random urine albumin/creatine ratio.

2. Integrate decision support into the workflow. Many EHRs can integrate decision support tools to help your practice meet process measures that have been shown to improve outcomes, such as ordering labs like A_1c and lipids, vaccinations, and referrals to specialists for eye screening examinations [35]. In addition, huddling with your medical support staff for 5–15 min prior to starting the day and again in the afternoon can help identify key items to be addressed in the patient’s visit. Some items to address can include selecting and gathering patient education materials, reviewing/ordering labs, and identifying the need for and generating referrals for DSME, mental health specialists, optometry/ophthalmology, vaccinations, and so on. Huddles should involve identifying key items for virtual as well as in-person visits. Research on huddles demonstrates improved team communication, efficiency of patient care, and shared responsibility for team function [36].

3. Adopt technology to increase touchpoints. The use of continuous glucose monitors to capture glucose data is a great way to comprehensively assess your patient’s response to lifestyle and pharmacological interventions over time. Many patients may have personal devices with sharing capabilities that enable your practice to perform remote analysis and interpretation. This can enhance telehealth visits and facilitate more meaningful discussions about glucose management with your patients [37].

There are also novel online programs that provide daily text messages to help support patient self-care behaviors. These programs are not only patient-centered but also improve outcomes [38]. In addition, patient outreach programs improve the patient/provider relationship and metabolic control [39]. To find a diabetes education program in your area, access: https://www.diabetes.org/tools-support/diabetes-education-program. In addition to the recommendations by the ADA Overcoming Therapeutic Inertia initiative framework [20], any way to increase access to care will provide your patients with additional opportunities to overcome TI. Some suggestions include:

1. Offer alternative appointment times. In the time of the COVID-19 pandemic, many practices have implemented alternatives to in-person visits such as telehealth visits. Individuals often cannot leave their workplaces for appointments due to a lack of vacation/sick time or secondary to workplace absenteeism [40]. Offering remote or in-person appointments at alternate times such as early in the morning before work or later in the afternoon, early evening, or even on weekends may help combat some of the issues that patients have with making and keeping appointments.

2. Allow self-scheduling. Providing patients with the ability to schedule follow-up appointments on their own may reduce incoming call volume and free up front-office staff for other important office workflow tasks. There is also the likelihood that self-scheduling may reduce rates of patient no-shows or cancellations, so it is worth exploring whether this would work in your practice setting.

3. Consider shared medical appointments. Shared medical appointments (SMAs) or “group visits’” can be a way to increase patients’ access to DSME and visits with their HCPs. There are a variety of ways in which SMAs can be conducted (e.g., monthly in a preselected patient population vs. a drop-in visit), but these appointments should consistently include time for patient education, discussion, and support as well as individualized medical care [41]. The benefits of SMAs range from reduction in HbA_1c, blood pressure, and low-density lipoprotein cholesterol [42, 43] to psychosocial aspects such as self-efficacy and empowerment [41]. Individuals who participate in SMAs are more likely to meet ADA standards of care [42] including adopting recommendations for exercise and nutrition [41]. This may be a result of the accountability and support perceived from SMAs [41]. In addition, SMAs add variety to an HCP’s schedule, improve workflow, and enhance relationships with patients [44].

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