Michael L. Parchman, MD1 Jacqueline A. Pugh, MD2 Raquel L. Romero, MD1 STAR Net Clinical Inertia or Competing Demands: The Case of the Elevated Hemoglobin A1c Michael L. Parchman, MD1 Jacqueline A. Pugh, MD2 Raquel L. Romero, MD1 1Department of Family & Community Medicine; 2Department of Medicine University of Texas Health Science Center, San Antonio

Problem Inadequate control of risk factors for micro- and macrovascular complications: Hemoglobin A1c Blood Pressure Lipids CV Risk Factor Most Recent Next Most Recent Most Distant HbA1C <= 7 43.1% 47.6 42.3 BP <= 130/80 47.2% 42.9 LDL <= 100 49.2% 49.7 44.3 Number of Risk Factors at Target: None 18.0% 16.3 17.4 One 36.3 38.8 39.6 Two 30.6 33.4 31.7 All Three 15.1% 11.5% 11.3%

Phillips LS, Branch WT et al. Clinical Inertia, Ann Intern Med 2001 "a recognition of a problem, but failure to act."

Diabetes Care; March 2005 45.1% of patients with specialists care had drug intensification versus 37.4% with primary care. (p = 0.009)

Clinical Inertia “Recognition of a problem, but failure to act.” - Phillips LS*; 2001 Ann Intern Med “Failure of providers to initiate or intensify therapy appropriately.” Phillips LS*; 2005 Diabetes Care “Inadequate intensification of therapy by the provider” Ziemer DC…Phillips LS; Diabetes Educ 2005 *Division of Endocrinology and Metabolism, Dept of Medicine, Emory University, Atlanta Georgia

Potential Causes of “Clinical Inertia” Phillips et al; Ann Intern Med 2001 Overestimation of Amount of Care Provided Use of “soft” reasons to avoid intensification of therapy Lack of training

in●er●tia “The tendency of a body to resist acceleration…” “The tendency of a body at rest to remain at rest” “Resistance to change or motion” Webster’s New College Dictionary 1995

Question? Is clinical inertia a mis-specification of the nature of the problem because of the perspective of those outside of primary care?

Competing Demands Multiple complex demands during the average physician-patient encounter Clinicians and patients prioritize those demands Address the most pressing or symptomatic problems or issues Defer less urgent demands to future encounters Jaen CR, Stange KC, Nutting PA . Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71

Evidence of Competing Demands Initiating and completing depression care therapy Nutting PA; 2000 Influence recommendations for mammography screening Nutting PA; 2001 Impede effective tobacco cessation counseling efforts Jaen CR; 2001 Limit the treatment of unrelated medical disorders in patients with a chronic illness Redelmeier DA. NEJM; 1998

Purpose To directly observe primary care encounters by patients with type 2 diabetes for evidence of competing demands. Hypotheses: A change in medication for elevated HbA1c will be positively associated with length of encounter A change in medication will be inversely associated with the number of patient complaints per minute. If there is no change in medication, then number of days to the next scheduled encounter will decrease as HbA1c increases

Methods 20 Primary Care Clinics/Practices Trained Observer STAR Net Methods 20 Primary Care Clinics/Practices South Texas Ambulatory Research Network (STARNet) Trained Observer 8-12 consecutive patient encounters per clinic Direct Observation of encounters by patients with Type 2 Diabetes

Measurements Taken Length of encounter: time physician was in exam room Number of patient symptoms/complaints Any change in oral hypoglycemic or insulin Number of days to next scheduled follow-up appointment Most recent HbA1c abstracted from chart

Results: Patient and Encounter Characteristics (n=211) % or Mean (S.D) Change in medication 28.6% Length of encounter (minutes) 17.5(8.8) # Symptoms or Complaints 2.0 (1.9) Number of Days to Next Scheduled Appointment 63.0 (43.3) HbA1c > 7% 55.5%

HbA1c and Change in Medication (All Encounters, n=211) However, no change in medication in 57% of encounters if A1c > 8%; 62.6% if A1c>7% t-test = 3.96, p = 0.001

NOTE! All subsequent analyses are only for encounters with HbA1c > 7.0% n=101

Change in Meds and Length of Visit Chi-square = 8.39 ; p=0.015

Patient Symptoms/Complaints and Change in Medication t-test = 2.01, p = 0.04

HbA1c and Days to Next Scheduled Appointment Pearson “r” p-value Change -0.06 0.74 No Change -.27 0.04

HbA1c and Days to Next Scheduled Appointment (No Change)

Logistic Regression: Change in Meds? (No/Yes) Parameter Odds Ratio Lower 95%CI Upper 95%CI Length of visit (minutes) 1.08 1.02 1.15 Number of Patient Symptoms 0.70 0.52 0.93

Change in Meds, Visit Length and Patient Complaint

Conclusions “Clinical Inertia” is a mis-specification of the nature of the problem in primary care encounters Competing Demands may partly explain the observed “failure” to intensify therapy for HbA1c Longitudinal follow-up studies are needed to examine the content of a series of encounters to understand the dynamics of care

Acknowledgements Support for this study provided by Agency for Healthcare Research and Quality (K08 HS013008-02) South Texas Health Research Center