PREVALENCE OF CLINICAL GUIDELINE-DIRECTED TREATMENT INTENSIFICATION IN DIABETES MELLITUS: A SYSTEMATIC REVIEW

Purpose: In patients with type 2 diabetes mellitus (T2DM), long term maintenance of glycemic control requires appropriate treatment intensification, according to clinical guidelines.  However, clinicians often hesitate to intensify treatment, often called clinical inertia, for a variety of reasons. This may contribute to poor health outcomes, especially when combined with other factors, such as patient non-adherence. We seek to evaluate the prevalence of clinical inertia, as measured by the rate of treatment intensification.

Methods: Systematic literature search was conducted using in PubMed, Embase, and Cochrane Central through 02/2014 using terms for type 2 diabetes, treatment intensification, and clinical inertia. Studies were included if they were observational studies (cohort or cross-sectional studies) in patients with type 2 diabetes and reported the rates of treatment intensification.

Results: A total of 18 studies (n=43,305) representing both prospective and retrospective cohort designs, following patients for a median of 12 months (range 6 to 24 months) were identified. In these studies, the indication for treatment intensification was defined by the study and varied from A1c>7% to A1c>8%. Treatment intensification given to patients varied from the initiation of pharmacotherapy in patients only on diet and exercise, dose increase of existing medications, or the addition of another medication. Two studies evaluating numbers of patient encounters at their primary care provider found that 26.7 to 36% of visits resulted in treatment intensification when patients were indicated. Of the remaining 16 studies which looked at the numbers of patients who require additional therapy, a median of 49.3% (range 7 to 74.6%) of patients received intensified therapy. A few studies further evaluated potential predictors of treatment intensification and found that intensified therapy was more likely when patients had higher baseline A1c (7 studies), were younger (2 studies), had other medications for co-morbid conditions (2 studies), and had higher adherence rates to their current regimens (2 studies).

Conclusions: In real-world settings, a significant proportion of eligible patients fail to receive the treatment intensification based on clinical guidelines. Further research is needed to determine provider beliefs and attitudes regarding treatment intensification.