Primary care diabetes treatment decision aid may miss heart of problem
medwireNews: Although helpful for primary care physicians, a type 2 diabetes treatment decision support tool may be missing the point for most people with poorly controlled glucose levels, suggest findings from a pilot study.
The cluster randomized controlled trial involving 14 primary care practices tested the effect of the DECIDE computer-based clinical decision support system for general practitioners (GPs), “developed to address clinical inertia and medication intensification.”
GPs used the tool when considering options for people younger than 75 years with type 2 diabetes who had suboptimal control of glycated hemoglobin (HbA1c; ≥70 mmol/mol; 8.6%) and/or blood pressure (≥150/95 mmHg).
The participating GPs liked the proactive focus on this subgroup of their patients; however, “they were sceptical about the role of newer medications for these patients and thought that patient-factors predominantly explained suboptimal control, such as non-engagement with healthcare services, reduced adherence with medications, multimorbidity and frailty,” write the researchers in BMJ Open.
Indeed, despite the GPs recording a total of 117 pharmacologic and 210 non-pharmacologic management intensification actions, the intervention had no significant effect on patients’ HbA1c levels over the 4 months of the study. Average HbA1c improved from 83.4 to 69.0 mmol/mol (9.8 to 8.5%) in the 57 patients from the intervention group, and from 79.0 to 70.8 mmol/mol (9.4 to 8.6%) in the 62 from the control group. There was also no effect on blood pressure or cholesterol levels.
The GPs described people in the targeted patient subgroup “as ‘falling through cracks’ and not attending or engaging in healthcare, despite robust practice procedures to call them back for review,” say Mark Murphy (Royal College of Surgeons, Dublin, Ireland) and study co-authors.
“When they did attend, some were perceived as difficult to manage or as ‘heart break’ patients.”
For this reason, some GPs felt that suboptimal control was “acceptable and understandable,” and the team therefore suggests that perceived clinical inertia “should not be seen simply through a negative lens or viewed as medical conservatism.”
Nonetheless, the GPs were broadly positive about the tool, reporting that they liked having the medication options and evidence laid out, especially in the light of the increasing complexity of type 2 diabetes medications, and that it supported their engagements with patients and generated renewed enthusiasm among practice staff.
“Our study suggests that delays in treatment escalation cannot be easily modified,” say Murphy and team, although they note that a definitive randomized trial would be necessary to confirm this.
They say the DECIDE intervention “met preplanned continuation criteria to progress” to such a trial, but add that “issues raised in the process evaluation would need to be addressed.”
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