1. 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

2. 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%

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

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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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%

15. 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

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

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

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

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

20. HbA1c and Days to Next Scheduled Appointment (No Change)

21. 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

22. Change in Meds, Visit Length and Patient Complaint

23. 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

24. Acknowledgements Support for this study provided by
Agency for Healthcare Research and Quality (K08 HS )
South Texas Health Research Center