Clinical Inertia Research Articles

CLINICAL INERTIA AND ADHERENCE IN THE CROATIAN RURAL AREA DAMAGED BY AN EARTHQUAKE. “THE SILENT KILLER HUNT”-CROATIAN SOCIETY OF HYPERTENSION PROJECT

Objective: Adherence to medical advice is a major factor in treating hypertension. Motivation to implement lifestyle changes is as important as taking medications. To gain a better understanding of patient compliance our aim was to find out patients’ adherence to physicians’ medical advice. Design and method: A survey was conducted on a sample of 214 subjects as a part of a project ’The Silent Killer Hunt’, which targets populations at risk for developing hypertension (opportunistic screening). The participants were given a questionnaire containing two types of questions, the first one being about the recommendation they were or were not given by their general practitioner, and the second one about their subsequent change of behavior. Jamovi was used for statistical analysis. Results: A total of 94.7% have received a recommendation to use medication for hypertension and 106 (49.5%) people have confirmed that they take their medication regularly. On the other hand, only 46.5% of the surveyed participants have been advised to decrease their body weight. Increasement in physical activity was suggested to 55.3% and a total of 30.2% and 28.6%, have not been successful in reducing their body weight and increasing their physical activity, respectively. More than half of the subjects (63.2%) were educated about lowering their salt intake. Conclusions: Clinical inertia and poor adherence were found in this rural area. Education of physicians and nurses is equally important as the education of patients and according to our results, it is even more important in this remote and poor part of Croatia.

Therapeutic inertia in type 2 diabetes mellitus: a fine line between advancing and de-intensifying.

Therapeutic inertia in type 2 diabetes mellitus: a fine line between advancing and de-intensifying.

Expert perspectives on strategic factors for the management and prevention of heart failure in Portugal

Introduction and objectivesHeart failure (HF) has significant morbidity and mortality, and its prevalence will continue to increase in the future. This unfavorable evolution requires reflection as well as recommendations and decisions based on expert critical and strategic appraisal. MethodsIn the Acceleration on Heart Failure Empowerment and Awareness – the Portuguese Challenge (ATHENA-PT) study, a range of strategic factors that represent the strengths, weaknesses, threats, and opportunities (SWOT) of HF in Portugal were established. These factors were assessed quantitatively by experts, to create a final SWOT matrix for the management and prevention of HF in Portugal and to outline recommendations. ResultsFor HF management, the panel emphasized the following strategic recommendations: (i) reimbursement of natriuretic peptides testing in primary healthcare; (ii) reimbursement of Doppler assessment in echocardiographic studies and promotion of detailed information in reports; (iii) intervention to improve the prognosis of patients with HF with preserved ejection fraction; (iv) ensuring effective healthcare transition between hospital and ambulatory units, using checklists/protocols; and (v) reinforcement and commitment to the training of primary health physicians and to the cardiac rehabilitation of patients. For the prevention of HF, the following recommendations/proposals were proposed: (i) campaigns to raise awareness of cardiovascular disease risk factors; (ii) promotion of physical exercise and healthy eating; and (iii) avoidance of therapeutic inertia in the management of risk factors. ConclusionsThe acknowledgment of various strategic factors and their prioritization by experts made it possible to create and reinforce a range of new strategic recommendations for the management and prevention of HF.

Roadmap for the Management of Type2 Diabetes and Hypertension in the Middle East: Review of the 2022 EVIDENT Summit.

Type2 diabetes mellitus (T2DM) and hypertension are leading risk factors for death and disability in the Middle East. Both conditions are highly prevalent, underdiagnosed and poorly controlled, highlighting an urgent need for a roadmap to overcome the barriers to optimal glycaemic and blood pressure management in this region. This review provides a summary of the Evidence in Diabetes and Hypertension Summit (EVIDENT) held in September 2022, which discussed current treatment guidelines, unmet clinical needs and strategies to improve treatment outcomes for patients with T2DM and hypertension in the Middle East. Current clinical guidelines recommend strict glycaemic and blood pressure targets, presenting several treatment options to achieve and maintain these targets and prevent complications. However, treatment targets are infrequently met in the Middle East, largely due to high clinical inertia among physicians and low medication adherence among patients. To address these challenges, clinical guidelines now provide individualised therapy recommendations based on drug profiles, patient preferences and management priorities. Efforts to improve the early detection of prediabetes, T2DM screening and intensive, early glucose control will minimise long-term complications. Physicians can use the T2DM Oral Agents Fact Checking programme to help navigate the wide range of treatment options and guide clinical decision-making. Sulfonylurea agents have been used successfully to manage T2DM; a newer agent, gliclazide MR (modified release formulation), has the advantages of a lower incidence of hypoglycaemia with no risk of cardiovascular events, weight neutrality and proven renal benefits. For patients with hypertension, single-pill combinations have been developed to improve efficacy and reduce treatment burden. In conjunction with pragmatic treatment algorithms and personalised therapies, greater investments in disease prevention, public awareness, training of healthcare providers, patient education, government policies and research are needed to improve the quality of care of patients with T2DM and/or hypertension in the Middle East.

Severe dyslipidemia title: known by patients, but is it treated?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with severe dyslipidemia (> 190 mg / dl) are considered in the clinical practice guidelines of high cardiovascular risk, therefore, diagnosis and treatment is essential, as well as the rest of the CV risk factors. But real-life records give us data of lack of control, justified by lack of adherence to treatment, underdiagnosis and therapeutic inertia among other factors. The aim of our work was to analyze patients knowledge about their dyslipidemia, treatment and the impact on their cardiovascular health. Materials and methods Patients with severe dyslipidemia (>190 mg/dl) from the familial hypercholesterolemia screening program were analyzed consecutively from February 1 – September 30, 2022. It was performed from Clinical Analysis, with an alarm system to detect severe dyslipidemia in people over 18 years of age in coordination with the Cardiovascular Prevention Unit of Cardiology and Genetics. All patients underwent a health questionnaire. Results n = 353. Mean age 52.2 years. 51.6% women (Table 1 baseline characteristics). 86.5% knew that they had dyslipidemia problems, mainly non-DM (85% vs 68%; p0.009), with familiy history (FH) of dyslipidemia (90% vs 81%;p 0.027) and older people (53.7 vs 47.1 years; p.001) But only 14.4% took treatment, patients with DM (31% vs. 13%; p0016), with FH of LDLhigh children (31% vs 12%; p 0.02), with personal history of CV disease (37% vs 13%; p 0.007) and BMI > 30 (20% vs 11%; p 0.017). 53.4% had taken treatment at some time, patients with hypertension (67% vs 49%;p 0.01), with family history of dyslipidemia (59% vs 44%; p 0.005), personal history of CV disease (87% vs 51%; p 0.005) and those over 40 years (55% vs 36%; p 0.016) 91.4% recognized the impact of dyslipidemia on the prognosis CV, mainly those with family history of dyslipidemia (94% vs 86%; p.017) and those under 40 years (100% vs 90.7%; p0.04). Conclusions A high percentage of patients recognize their dyslipidemia problem and the possible impact on their health, but less than 15% take lipid-lowering treatment.

Connected Insulin Pens and Caps: An Expert's Recommendation from the Area of Diabetes of the Spanish Endocrinology and Nutrition Society (SEEN).

Undoubtedly, technological advances have revolutionised diabetes management in recent years. The development of advanced closed hybrid loop insulin pumps or continuous glucose monitoring (CGM) systems, among others, have increased the quality of life and improved glycaemic control of people with diabetes. However, only some patients have access to such technology, and only some want to use it. CGM has become much more widespread, but in terms of insulin delivery, most people with type 1 diabetes (T1D) and almost all people with type 2 diabetes (T2D) on insulin therapy are treated with multiple-dose insulin injections (MDI) rather than an insulin pump. For these patients, using connected insulin pens or caps has shown benefits in reducing missed insulin injections and promoting correct administration over time. In addition, using these devices improves the quality of life and user satisfaction. The integration of insulin injection and CGM data facilitates both users and the healthcare team to analyse glucose control and implement appropriate therapeutic changes, reducing therapeutic inertia. This expert's recommendation reviews the characteristics of the devices marketed or in the process of being marketed and their available scientific evidence. Finally, it suggests the profile of users and professionals who would benefit most, the barriers to its generalisation and the changes in the care model that implementing these devices can bring with it.

Evidence for Age Bias Contributing to Therapeutic Inertia in Blood Pressure Management: A Secondary Analysis of SPRINT.

Despite evidence supporting the cardiovascular and cognitive benefits of intensive blood pressure management, older adults have the lowest rates of blood pressure control. We determined the association between age and therapeutic inertia (TI) in SPRINT (Systolic Blood Pressure Intervention Trial), and whether frailty, cognitive function, or gait speed moderate or mediate these associations. We performed a secondary analysis of SPRINT of participant visits with blood pressure above randomized treatment goal. We categorized baseline age as <60, 60 to <70, 70 to <80, and ≥80 years and TI as no antihypertensive medication intensification per participant visit. Generalized estimating equations generated odds ratios for TI associated with age, stratified by treatment group based on nested models adjusted for baseline frailty index score (fit [frailty index, ≤0.10], less fit [0.10<frailty index≤0.21], and frail [0.21<frailty index]), cognitive function by Montreal cognitive assessment, and gait speed (participants ≥75 years of age), separately. Participants 60 to <70, 70 to <80, and ≥80 years of age had a higher prevalence of TI in both treatment groups versus participants <60 years of age (standard: 59.7%, 60.5%, and 60.1% versus 56.0%; 29 527 participant visits; intensive: 55.1%, 57.2%, and 57.8% versus 53.8%; 47 129 participant visits). The adjusted odds ratios for TI comparing participants ≥80 versus <60 years of age were 1.32 (95% CI, 1.14-1.53) and 1.25 (95% CI, 1.11-1.41) in the standard and intensive treatment groups, respectively. Adjustment for frailty, cognitive function, or gait speed did not attenuate the association or demonstrate effect modification (all Pinteraction, >0.10). Older age is associated with greater TI independent of physical or cognitive function, implying age bias in hypertension management.

A drug recommender system for the treatment of hypertension

BackgroundOne third (20% to 30%) of patients suffering from hypertension show increased blood pressure resistant to treatment. This resistance often has multifactorial causes, like therapeutic inertia and inappropriate medication but also poor patient adherence. Evidence-based guidelines aim to support appropriate health care decisions. However, (i) research and appraisal of clinical guidelines is often not practicable in daily routine care and (ii) guidelines alone are often insufficient to make suitable and personalized treatment decisions. Shared decision-making (SDM) can significantly improve patient adherence, but is also difficult to implement in routine care due to time constraints.MethodsClinical Decision Support Systems (CDSSs), designed to support clinical decision-making by providing explainable and personalized treatment recommendations, are expected to remedy the aforementioned issues. In this work we describe a digital recommendation system for the pharmaceutical treatment of hypertension and compare its recommendations with clinical experts. The proposed therapy recommender algorithm combines external evidence (knowledge-based) – derived from clinical guidelines and drugs’ professional information – with information stored in routine care data (data-based) – derived from 298 medical records and 900 doctor-patient contacts from 7 general practitioners practices. The developed Graphical User Interface (GUI) visualizes recommendations along with personalized treatment information and intents to support SDM. The CDSS was evaluated on 23 artificial test patients (case vignettes), by comparing its output with recommendations from five specialized physicians.ResultsThe results show that the proposed algorithm provides personalized treatment recommendations with large agreement with clinical experts. This is true for agreement with all experts (agree_all), with any expert (agree_any), and with the majority vote of all experts (agree_majority). The performance of a solely data-based approach can be additionally improved by applying evidence-based rules (external evidence). When comparing the achieved results (agree_all) with the inter-rater agreement among experts, the CDSS’s recommendations partly agree more often with the experts than the experts among each other.ConclusionOverall, the feasibility and performance of medication recommendation systems for the treatment of hypertension could be shown. The major challenges when developing such a CDSS arise from (i) the availability of sufficient and appropriate training and evaluation data and (ii) the absence of standardized medical knowledge such as computerized guidelines. If these challenges are solved, such treatment recommender systems can support physicians with exploiting knowledge stored in routine care data, help to comply with the best available clinical evidence and increase the adherence of the patient by reducing site-effects and individualizing therapies.

Barriers to Guideline-Directed Anticoagulation in Patients With Atrial Fibrillation: New Approaches to an Old Problem.

Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with guideline-directed use of anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease, and choice of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk, and implicit bias. For patients, negative preconceptions of therapy, impact of therapy on day-to-day life, and the nocebo effect pose significant barriers. Both groups are affected by poor education. Utility of a single-pronged approach directed toward clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies using shared-decision models. Furthermore, there is emerging evidence for use of integrated models of care, which have shown improved efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation, with translated improved outcomes in clinical trials. This narrative review article aims to investigate the physician and health system, patient, and drug therapy and disease barriers to uptake of guideline-directed anticoagulation in treatment of nonvalvular atrial fibrillation.

Abstract #1413009: Post Snake Bite Panhypopituitarism – Delay in Diagnosis or Delayed Presentation

Panhypopituitarism is a condition of inadequate or absent production of the anterior pituitary hormones. Simmonds’ disease was first described in 1914 by the German pathologist Simmond. Post snake bite panhypopituitarism is a described entity. Hypopituitarism following Russell’s viper bite was first reported in 1976 by Eapen et al in three adults from Kerala in South India. Most of the cases are diagnosed long after the snake bite, and this delay has been attributed to clinical inertia and lack of awareness. But on careful analysis of the case reports, it is found that at least a few of them started having symptoms after a latent period, which can be up to 5 years. We present 7 cases of post snakebite hypopituitarism, which were diagnosed late, but also had a delayed onset of symptoms. 7 patients, who were diagnosed to have post snake bite hypopituitarism between May 2020 and May 2022 were studied. All patients were male. The type of snake, the complications and treatment initially given were studied, and then the time of onset of symptoms of hormonal deficiencies was collected. All patients underwent relevant hormonal tests, including dynamic tests and imaging for pituitary. All patients were male, all were bitten by Russels viper, all had hypotension after the bite and required blood transfusions and hemodialysis. The mean duration from the snake bite to the diagnosis was 7.75 years. The onset of symptoms was also delayed, with symptoms occurring an average 4.25 years after the snake bite. All patients had symptoms of hypogonadism, which was the first symptom to occur in 5 out of 7 patients. Lethargy, tiredness, weakness were present in all and appeared next, a mean of 6 months later. Symptoms of adrenal insufficiency appeared in all patients, a mean of 2.5 years later. Adrenal crisis occurred in patients, a mean of 13 months later. On hormonal evaluation all patients had panhypopituitarism, (low FSH/LH Testosterone, Cortisol, IGF1, and FT4). MRI done showed empty sella in 5 patients and small anterior pituitary in 2 patients. Hypopituitarism is an important sequel of Russell’s viper bite in South India. A high degree of suspicion is needed to diagnose this condition following Russell’s viper bite. Contrary to our earlier understanding of post snake bite hypopituitarism, the pituitary damage is not a single time event, but a gradual loss of pituitary function initiated by the snake bite, which results in a delayed appearance of symptoms. The sequence of loss of pituitary hormone functions- Gonadotropin- GH-Thyrotropin-ACTH also points to the same fact. The possible explanation is drawn from the analogy of Sheehan’s syndrome presenting late, where the late presentation is due to an autoimmune destruction, initiated by the snake bite (Anti pituitary antibody positive). The delay in diagnosis is at least contributed by the late appearance of panhypopituitarism, and the diagnosis should be considered in all patients with significant viper bite, presenting with symptoms suggestive of panhypopituitarism, however late may the onset of symptoms be.

A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes.

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

Integrated analysis for treatment scheme of sodium–glucose cotransporter 2 inhibitors in patients with diabetic kidney disease: a real-world study

Sodium–glucose cotransporter 2 inhibitors (SGLT2i) are recommended for type 2 diabetes mellitus patients with impaired renal function, but the actual situation of SGLT2i using is unclear. Therefore, in this real-world study, we analyzed the treatment scheme and clinical characteristics of SGLT2i in patients with diabetic kidney disease (DKD). We included DKD patients hospitalized in the First Affiliated Hospital of Zhengzhou University from October 2017 to March 2020. The Apriori algorithm of association rules was used to analysis treatment scheme prescribing SGLT2i and other different combinations of hypoglycemic drugs. SGLT2i was used in 781 (12.3%) of 6336 DKD patients, both number and proportion of patients using SGLT2i increased from 2017 to 2020 (1.9% to 33%). Nighty-eight percent of all DKD patients using SGLT2i were combined with other glucose-lowering agents, and insulin, metformin and alpha-glucosidase inhibitors are most commonly used in combination with hypoglycemic drugs. Multivariate analysis showed that compared with non-SGLT2i group, patients using SGLT2i were associated with younger age, higher BMI, higher HbA1c, preserved kidney function, dyslipidemia and combined with ACEI/ARB and statins. In this real-world study, use of SGLT2i in DKD patients is still low. Most patients performed younger age and in the early stages of chronic kidney disease with poor glycemic control. Clinical inertia should be overcome to fully exert the cardiorenal protective effects of SGLT2 inhibitors, with attention to rational drug use.

Clinical inertia on insulin treatment in the primary care setting

Clinical inertia on insulin treatment in the primary care setting

Identifying Reasons for Statin Nonuse in Patients With Diabetes Using Deep Learning of Electronic Health Records.

Background Statins are guideline-recommended medications that reduce cardiovascular events in patients with diabetes. Yet, statin use is concerningly low in this high-risk population. Identifying reasons for statin nonuse, which are typically described in unstructured electronic health record data, can inform targeted system interventions to improve statin use. We aimed to leverage a deep learning approach to identify reasons for statin nonuse in patients with diabetes. Methods and Results Adults with diabetes and no statin prescriptions were identified from a multiethnic, multisite Northern California electronic health record cohort from 2014 to 2020. We used a benchmark deep learning natural language processing approach (Clinical Bidirectional Encoder Representations from Transformers) to identify statin nonuse and reasons for statin nonuse from unstructured electronic health record data. Performance was evaluated against expert clinician review from manual annotation of clinical notes and compared with other natural language processing approaches. Of 33 461 patients with diabetes (mean age 59±15 years, 49% women, 36% White patients, 24% Asian patients, and 15% Hispanic patients), 47% (15 580) had no statin prescriptions. From unstructured data, Clinical Bidirectional Encoder Representations from Transformers accurately identified statin nonuse (area under receiver operating characteristic curve [AUC] 0.99 [0.98-1.0]) and key patient (eg, side effects/contraindications), clinician (eg, guideline-discordant practice), and system reasons (eg, clinical inertia) for statin nonuse (AUC 0.90 [0.86-0.93]) and outperformed other natural language processing approaches. Reasons for nonuse varied by clinical and demographic characteristics, including race and ethnicity. Conclusions A deep learning algorithm identified statin nonuse and actionable reasons for statin nonuse in patients with diabetes. Findings may enable targeted interventions to improve guideline-directed statin use and be scaled to other evidence-based therapies.

Design of a Non-Interventional Study to Assess Neurologists' Perspectives and Pharmacological Treatment Decisions in Early Alzheimer's Disease.

The current therapeutic landscape of Alzheimer's disease (AD) is evolving rapidly. Our treatment options include new anti-amyloid-β protein disease-modifying therapies (DMTs) that decrease cognitive decline in patients with early AD (prodromal and mild AD dementia). Despite these advances, we have limited information on how neurologists would apply the results of recent DMT trials to make treatment decisions. Our goal is to identify factors associated with the use of new AD DMTs among neurologists applying concepts from behavioral economics. This non-interventional, cross-sectional, web-based study will assess 400 neurologists with expertise in AD from across Spain. Participants will start by completing demographic information, practice settings, and a behavioral battery to address their tolerance to uncertainty and risk preferences. Participants will then be presented with 10 simulated case scenarios or vignettes of common encounters in patients with early AD to evaluate treatment initiation with anti-amyloid-β DMTs (e.g., aducanumab, lecanemab, etc.). The primary outcomes will be therapeutic inertia and suboptimal decisions. Discrete choice experiments will be used to determine the weight of factors influencing treatment choices. The results of this study will provide new insights into a better understanding of the most relevant factors associated with therapeutic decisions on the use of DMTs, assessing how neurologists handle uncertainty when making treatment choices, and identifying the prevalence of therapeutic inertia in the management of early AD.

Trajectory of glycated haemoglobin over time, using real-world data, in type 2 diabetes patients with obesity on a U-100 basal-bolus insulin regimen.

To identify patient clusters with poor glucose control among type 2 diabetes mellitus (T2DM) patients with obesity who are receiving basal-bolus insulin and to identify the potential therapeutic inertia factors associated with poor control. Glycated haemoglobin (HbA1c) trajectories across a 3-year period were structured at 6-month intervals for a retrospective cohort of T2DM patients with obesity on basal-bolus insulin from the Veterans' Health Administration database. Based on each patient's longitudinal HbA1c features, an unsupervised clustering procedure was used to determine the numbers of clusters and associated trajectory patterns. Multinomial logistic regression was used to examine the association between HbA1c trajectory clusters and patient characteristics/treatment patterns. A total of 51 273 patients were included, of whom 11.2% were in a subgroup with persistent missingness of HbA1c values. For those with sufficient HbA1c observations, cluster analysis indicated six distinct HbA1c trajectories: stable low (35.8%); stable high (20.8%); descending low (10.5%); ascending low (10.2%); descending high (5.7%); and ascending high (5.7%). Being of Black ethnicity, not initiating noninsulin antihyperglycaemic agents (sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists or thiazolidinediones) or concentrated insulin, low adherence (measured by proportion of days covered), and reduced insulin prescription refills were factors associated with poorer HbA1c clusters; similar factors were associated with persistent HbA1c missingness. The present study found the potential for therapeutic inertia among a significant proportion of T2DM patients with obesity on basal-bolus insulin. Subgrouping T2DM patients based on HbA1c missingness and HbA1c trajectories can inform disease management strategies.

Knowledge, Perceptions, and Perspectives of Medical Students Regarding the Use of Antibiotics and Antibiotic Resistance: A Qualitative Research in Galicia, Spain

Antibiotic resistance is a significant public health concern, with numerous studies linking antibiotic consumption to the development of resistance. As medical students will play a pivotal role in prescribing antibiotics, this research aimed to identify their perceptions of current use and factors that could influence future inappropriate use of antibiotics. The study employed a qualitative research approach using Focus Group discussions (FGs) consisting of students from the final theoretical course of the Medicine degree. The FGs were conducted based on a pre-script developed from factors contributing to antibiotic misuse identified in previous studies. All sessions were recorded and transcribed for analysis by two independent researchers, with all participants signing informed consent. Seven focus groups were conducted, with a total of 35 participants. The study identified factors that could influence the future prescription of antibiotics, including the low applicability of knowledge, insecurity, clinical inertia, difficulties in the doctor-patient relationship, unawareness of available updates on the topic, and inability to assess their validity. The students did not perceive antibiotic resistance as a current problem. However, the study found several modifiable factors in medical students that could explain the misuse of antibiotics, and developing specific strategies could help improve their use.

Use of the FreeStyle Libre system and diabetes treatment progression in T2DM: Results from a retrospective cohort study using a Canadian private payer claims database.

Up to one-third of Canadians are estimated to be living with prediabetes or diabetes. A retrospective study using Canadian private drug claims data was conducted to investigate whether flash glucose monitoring using the FreeStyle Libre system (FSL) among people with type 2 diabetes mellitus (T2DM) in Canada can be associated with changes in treatment intensification when compared with blood glucose monitoring (BGM) alone. Using a Canadian national private drug claims database comprising approximately 50% coverage of insured individuals in Canada, cohorts of people with T2DM using FSL or BGM were identified algorithmically based on treatment history and followed over a 24-month study period, tracking their progression in diabetes treatment therapy. The Andersen-Gill model for recurrent time-to-event data was used to evaluate whether the rate of treatment progression differs between the FSL and BGM treatment cohorts. The survival function was used to calculate comparative treatment progression probabilities between the cohorts. In total, 373 871 people with T2DM met the inclusion criteria. Across treatment (FSL) and control (BGM) groups, people using FSL had a higher probability of treatment progression compared with BGM alone, with a relative risk ranging between 1.86 and 2.81 (p < .001). A higher probability of treatment progression was independent of the diabetes treatment at the enrolment date (index date) or the patient status, and independent of whether patients were treatment naïve or on established diabetes therapy. Assessment of the ending treatment relative to the starting therapy indicated that dynamic treatment changes were most evident for patients in the FSL cohort and that the FSL cohort had a much greater portion of patients who ended with insulin treatment (when they started with non-insulin treatment) compared with the BGM cohort. People with T2DM using FSL had a greater probability for treatment progression compared with BGM alone, irrespective of the starting therapy, which may suggest that FSL can be used to support escalation of diabetes therapy to improve therapeutic inertia in T2DM.

SGLT2 inhibition in heart failure with reduced or preserved ejection fraction: Finding the right patients to treat.

Sodium-glucose transport inhibitors (SGLT2i) are effective in heart failure (HF) with ejection fraction (EF) <40% (referred to as HF with reduced EF - HFrEF) and left ventricular EF (LVEF) >40%. Current evidence suggests that SGLT2i should be initiated across a large spectrum of EFs and renal function in patients with HF and with and without diabetes. We reviewed the benefits of SGLT2i in the entire spectrum of HF and provided some clues that may guide physicians in their strategy of initiating and maintaining SGLT2i (with or without SGLT1i effect) therapy. Taken together, the evidence thus far arises from an array of trials performed in different settings (acute/chronic), risk categories, and phenotypes of HF (HFrEF/HFpEF), and in addition to the most common HF therapies, supports the homogenous effect of SGLT2i across a large spectrum of patients with HF. SGLT2i appear to be effective and well-tolerated drugs in the majority of clinical HF scenarios, regardless of LVEF, estimated glomerular filtration rate, diabetic status or the level of the acuteness of the clinical setting. Therefore, most patients with HF should be treated with SGLT2i. However, in the face of the therapeutic inertia that has been observed in HF over the past decades, the actual implementation of SGLT2i in routine practice remains the most significant challenge.

Transparent machine learning suggests a key driver in the decision to startinsulin therapy in individuals with type 2 diabetes.

The objective of this study is to establish a predictive model using transparent machine learning (ML) to identify any drivers that characterize therapeutic inertia. Data in the form of both descriptive and dynamic variables collected from electronic records of 1.5 million patients seen at clinics within the Italian Association of Medical Diabetologists between 2005-2019 were analyzed using logic learning machine (LLM), a "clear box" ML technique. Data were subjected to a first stage of modeling to allow ML to automatically select the most relevant factors related to inertia, and then four further modeling steps individuated key variables that discriminated the presence or absence of inertia. The LLM model revealed a key role for average glycated hemoglobin (HbA1c) threshold values correlated with the presence or absence of insulin therapeutic inertia with an accuracy of 0.79. The model indicated that a patient's dynamic rather than static glycemic profile has a greater effect on therapeutic inertia. Specifically, the difference in HbA1c between two consecutive visits, what we call the HbA1c gap, plays a crucial role. Namely, insulin therapeutic inertia is correlated with an HbA1c gap of <6.6 mmol/mol (0.6%), but not with an HbA1c gap of >11 mmol/mol (1.0%). The results reveal, for the first time, the interrelationship between a patient's glycemic trend defined by sequential HbA1c measurements and timely or delayed initiation of insulin therapy. The results further demonstrate that LLM can provide insight in support of evidence-based medicine using real world data.