Clinical inertia in response to inadequate glycemic control - Do specialists differ from primary care physicians?
Clinical inertia in response to inadequate glycemic control - Do specialists differ from primary care physicians?
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DOI：
10.2337/diacare.28.3.600
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发表时间：
2005-03-01
期刊：
影响因子：
16.2
通讯作者：
van Walraven, C
中科院分区：
文献类型：
--
作者：
Shah, BR;Hux, JE;van Walraven, C
目的——血糖控制不足的糖尿病患者应该加强管理。不这样做可以被称为“临床惰性”。因为数据表明专科护理比初级护理能更好地控制，所以我们评估了专科护理是否比初级护理医生表现出更少的临床惰性。 研究设计和方法 - 使用管理数据，我们研究了安大略省东部 65 岁或以上的所有非胰岛素需要的糖尿病患者，这些患者在 1999 年 9 月至 2000 年 8 月期间 Alc 结果 > 8%。 在升高的 Alc 测试之前和之后 4 个月的阻断被定义为 1) 添加新的口服药物，2) 增加现有口服药物的剂量，或 3) 开始使用胰岛素。基于倾向评分的匹配用于控制组间混杂。 结果 - 591 名患者接受专科护理，1,911 名患者仅接受初级护理。在匹配队列中，接受专科护理的患者中有 45.1% 接受了药物强化治疗，而接受初级护理的患者则有 37.4%（P = 0.009）。这种差异大部分归因于专家针对升高的 Ale 更频繁地开始使用胰岛素。 结论 - 无论医生的专业如何，只有不到一半的高 Alc 水平患者会强化药物治疗。专家们比初级保健医生更积极地开始使用胰岛素，这可能导致专科护理中的 Alc 水平较低。帮助患者和医生认识并克服临床惯性的干预措施应改善人群的糖尿病护理。
OBJECTIVE - Diabetic patients with inadequate glycemic control ought to have their management intensified. Failure to do so can be termed "clinical inertia." Because data suggest that specialist care results in better control than primary care, we evaluated whether specialists demonstrated less clinical inertia than primary care physicians.RESEARCH DESIGN AND METHODS - Using administrative data, we studied all non-insulm-requiring diabetic patients in eastern Ontario agd 65 or older who had Alc results >8% between September 1999 and August 2000. Drug intensification was measured by comparing glucose-lowering drug regimens in 4-month blocks before and after the elevated Alc test and was defined as 1) the addition of a new oral drug, 2)a dose increase of an existing oral drug, or 3) the initiation of insulin. Propensity score-based matching was used to control for confounding between groups.RESULTS - There were 591 patients with specialist care and 1,911 with exclusively primary care. In the matched cohorts, 45.1% of patients with specialist care versus 37.4%,with primary care had drug intensification (P = 0.009). Most of this difference was attributed to specialists' more frequent initiation of insulin in response to elevated Ale.CONCLUSIONS - Fewer than one-half of patients with high Alc levels had intensification of their medications, regardless of specialty of their physician. Specialists were more aggressive with insulin initiation than primary care physicians, which may contribute to the lower Alc levels seen with specialist care. Interventions assisting patients and physicians to recognize and overcome clinical inertia should improve diabetes care in the population.