Strategies for overcoming therapeutic inertia in type 2 diabetes: A systematic review and meta‐analysis

Abstract

Aims To systematically investigate the effect of interventions to overcome therapeutic inertia on glycaemic control in individuals with type 2 diabetes. Materials and Methods We electronically searched for randomized controlled trials or quasi‐experimental studies published between January 1, 2004 and December 31, 2019 evaluating the effect of interventions on glycated haemoglobin (HbA1c) control. Characteristics of included studies and HbA1c difference between intervention and control arms (main outcome) were extracted. Interventions were grouped as: care management and patient education; nurse or certified diabetes educator (CDE); pharmacist; or physician‐based. Results Thirty‐six studies including 22 243 individuals were combined in nonlinear random‐effects meta‐regressions; the median (range) duration of intervention was 1 year (0.9 to 36 months). Compared to the control arm, HbA1c reduction ranged from: −17.7 mmol/mol (−1.62%) to −4.4 mmol/mol (−0.40%) for nurse‐ or CDE‐based interventions; −13.1 mmol/mol (−1.20%) to 3.3 mmol/mol (0.30%) for care management and patient education interventions; −9.8 mmol/mol (−0.90%) to −6.6 mmol/mol (−0.60%) for pharmacist‐based interventions; and −4.4 mmol/mol (−0.40%) to 2.8 mmol/mol (0.26%) for physician‐based interventions. Across the included studies, a reduction in HbA1c was observed only during the first year (6 months: −4.2 mmol/mol, 95% confidence interval [CI] −6.2, −2.2 [−0.38%, 95% CI −0.56, −0.20]; 1 year: −1.6 mmol/mol, 95% CI −3.3, 0.1 [−0.15%, 95% CI −0.30, 0.01]) and in individuals with preintervention HbA1c >75 mmol/mol (9%). Conclusions The most effective approaches to mitigating therapeutic inertia and improving HbA1c were those that empower nonphysician providers such as pharmacists, nurses and diabetes educators to initiate and intensify treatment independently, supported by appropriate guidelines.

2022 National Standards for Diabetes Self-Management Education and Support

“…Research studies show that Diabetes Care and Education Specialists can support intensification of treatment plans to achieve glycemic, blood pressure, and lipid targets through the implementation of diabetes management protocols (131). Furthermore, a recent systematic review and meta-analysis adds to the growing body of evidence that professionals who are not physicians, such as the Diabetes Care and Education Specialist, are well positioned and should be empowered to initiate and intensify treatment plans when supported by appropriate guidelines (20). Use of digital technology (e.g., cloud-based, telehealth, data management platforms, apps, and social media) enhances the ability to employ a technology enabled self-management feedback loop with four key elements-two-way communication, analysis of PGHD, customized education, and personcentered feedback-to provide real-time engagement in selfmanagement, as well as enable and empower PWD to effectively communicate with their care team (26).…”

“…Support of DSMES services also involves inclusive healthcare teams, which at minimum, include the PWD, the referring physician/ other qualified healthcare professional, and the diabetes care and education specialist. The inclusion of and communication between various healthcare team members, specifically diabetes care and education specialists, has effectively improved diabetes care (20). Ultimately, organizational support of evidence-based DSMES is necessary to ensure that these services are available in the delivery method preferred and accessible and adequately utilized by the PWD.…”

“…The 2022 National Standards update is meant to be a universal document that is easy to understand and can be implemented by the entire healthcare community. DSMES teams in collaboration with primary care have been shown to be the most effective approach to overcome therapeutic inertia (20). While the National Standards can be implemented in any care setting, the Chronic Care Model (CCM), which replaced the Acute Care Model as a leading practice in the 1990s, focuses on proactively managing chronic diseases (21).…”

2022 National Standards for Diabetes Self-Management Education and Support

“…The inclusion of and communication between various health care team members, specifically diabetes care and education specialists, has effectively improved diabetes care. 20 Ultimately, organizational support of evidence-based DSMES is necessary to ensure that these services are available in the delivery method preferred and accessible and adequately utilized by the person with diabetes. Support could also be from expert stakeholders, who can provide purposeful input and advocacy to promote awareness, value, access, increased utilization, and quality.…”

“…DSMES teams in collaboration with primary care have been shown to be the most effective approach to overcome therapeutic inertia. 20 Although the National Standards can be implemented in any care setting, the Chronic Care Model (CCM), which replaced the Acute Care Model as a leading practice in the 1990s, focuses on proactively managing chronic diseases. 21 Additionally, Minimally Disruptive Medicine (MDM) is a person-centered approach to health care that prioritizes the self-determined and self-chosen goals for life and health of PWD while minimizing the health care disruption on their lives.…”