Factors Associated with Diabetes-Related Clinical Inertia in a Managed Care Population and Its Effect on Hemoglobin A1c Goal Attainment: A Claims-Based Analysis

Despite evidence showing the benefits of treatment intensification following an elevated hemoglobin A1c (A1c), clinical inertia, or failure to establish and/or escalate treatment to achieve treatment goals, is a concern among patients diagnosed with type 2 diabetes (T2DM). Clinical inertia may contribute to increased health care utilization and costs due to poor clinical outcomes in MCOs. To (a) identify factors associated with clinical inertia in T2DM and (b) determine differences in A1c goal attainment between patients who experience clinical inertia versus treatment intensification in a commercially insured population. Medical and pharmacy claims data were used to identify commercially insured patients in a regional MCO with a recorded A1c ≥ 8.0% between January 1, 2013, and December 31, 2015. In the 4 months following the first elevated A1c value (index date), patients were classified into 2 groups: treatment intensification or clinical inertia. Treatment intensification was defined as the addition of ≥ 1 new noninsulin antihyperglycemic medication, the addition of insulin, or a dose increase of any current noninsulin antihyperglycemic medication. Patients were required to have ≥ 1 follow-up A1c value 6-12 months after the index date and continuous enrollment in the health plan for 12 months before and after the index date. Patients were excluded if they had a diagnosis for gestational diabetes or type 1 diabetes or if they were on insulin in the pre-index period. The primary outcome of attaining A1c < 7.0% was compared between groups after propensity score matching (PSM). Factors associated with clinical inertia were identified using logistic regression. 3,078 patients, with a mean (SD) age of 54.4 (10.6) years and a mean (SD) baseline A1c of 9.6% (1.7), were included in the study. Of these, 1,093 patients (36%) experienced clinical inertia. After PSM, 1,760 patients remained; 880 in each group. In the clinical inertia group, 23% of patients achieved an A1c < 7.0% in the post-index period, compared with 35% in the treatment intensification group (P < 0.001). A greater likelihood of experiencing clinical inertia was associated with baseline treatment with 2 (OR = 1.51, 95% CI = 1.22-2.86; P < 0.001) or ≥ 3 (OR = 1.78, 95% CI = 1.30-2.42; P < 0.001) antihyperglycemic medications (vs. none), baseline age ≥ 65 years (OR = 2.11, 95% CI = 1.63-2.74; P < 0.001), and diagnosis of coronary heart disease (OR = 1.44, 95% CI = 1.10-1.88; P = 0.007). A baseline A1