Therapeutic inertia in blood glucose management for gestational diabetes

Abstract

Therapeutic Inertia (TI) is a failure to initiate or intensify therapy when clinically appropriate. We aimed to define the frequency of TI in patients with gestational diabetes (GDM) and identify associated clinical factors. We conducted a retrospective cohort study of all visits post-GDM diagnosis for women who delivered between 1/2018-12/2019. Visits without recorded blood glucose (BG) logs were excluded. GDM was managed by individual clinicians including advanced practice nurses (APNs), physicians, and dieticians. Trained research personnel reviewed all electronic health record (EHR) notes, recording BG values by visit and assessing whether clinicians took actions such as dietary counseling, medication initiation, or medication titration to manage abnormal BG values. Internal guidelines recommend action when ≥50% of BG values are abnormal. Logistic regression with cluster-robust standard errors to allow for intragroup correlation by clinician was used to test the association between TI and a priori-selected covariates. During the study period, 76 clinicians performed 1,951 visits, and BG values were recorded for 632 (32%). On average, 28% of visit BG values were abnormal (IQR 14% - 46%) and action was taken 37.5% of the time. Most visits were managed by APNs (48%) followed by physicians (33%), dieticians (14%), and trainees (4%). Among 124 treatment-eligible visits, action occurred 58% of the time compared to 32% among 454 treatment ineligible visits. After adjusting for patient characteristics and accounting for correlation by individual clinicians, factors associated with TI included the number of issues addressed per visit and Asian race. Visits staffed by physicians were associated with a decreased odds of TI compared to visits staffed by APNs. In a real-world setting, therapeutic inertia, or failure to initiate or intensify therapy when clinically appropriate, occurred in 42% of visits and was associated with clinical factors including visit complexity and APN care.