A Cross-sectional Survey to Assess Reasons for Therapeutic Inertia in People With Type 2 Diabetes Mellitus and Preferred Strategies to Overcome It From the Perspectives of Persons With Diabetes and General/Family Practitioners: Results From the MOTION Study.

OBJECTIVES: Although multiple causes of therapeutic inertia in type 2 diabetes mellitus (T2DM) have been identified, few studies have addressed the behavioural aspects of treatment-intensification decisions among persons with type 2 diabetes (PwT2DM) and general practitioners/family practitioners (GPFPs). METHODS: A quantitative online survey was developed to capture from 300 PwT2DM and 100 GPFPs the following information: 1) perspectives on shared decision-making (SDM) related to treatment intensification, using the 9-item Shared Decision Making Questionnaire and the Shared Decision Making Questionnaire---physician version; 2) intentions to intensify treatments, using the Theory of Planned Behaviour (TPB); and 3) preferred strategies to overcome causes of therapeutic inertia in T2DM. Regression methods were applied post hoc to examine correlations with SDM scores, behavioural intentions and behaviours. RESULTS: SDM scores showed a significantly lower level of perceived involvement in decision-making related to treatment intensification among PwT2DM compared with GPFPs. The TPB identified that, for PwT2DM, attitudes, perceived behavioural control and age were associated with variation in intention to intensify treatment and, for GPFPs, perceived behavioural control and not being in a shared/group practice were associated with intentions to intensify treatment. PwT2DM behaviour, measured as hesitancy to intensify treatment, was associated with age. PwT2DM want more information to become more comfortable with the treatment decision-making process, whereas GPFPs desired support from other health professionals, and more time to address issues among PwT2DM. CONCLUSIONS: Strategies directed at providing GPFPs with tools/approaches to increase PwT2DM involvement in the decision-making process, such as behavioural coaching, decision aids and goal setting, may increase acceptance of treatment intensification, leading to a reduction in therapeutic inertia in T2DM.

Persons With Diabetes and General/Family Practitioner Perspectives Related to Therapeutic Inertia in Type 2 Diabetes Mellitus Using Qualitative Focus Groups and the Theoretical Domains Framework: Results From the MOTION Study.

OBJECTIVES: Therapeutic inertia in type 2 diabetes (T2DM) is the failure to receive timely treatment intensification as indicated according to T2DM treatment guidelines. Multifactorial causes of therapeutic inertia in T2DM have been documented at the level of persons with diabetes (PwD), health-care providers and health-care systems. METHODS: We developed a 3-part mixed-methods research program, called the Moving to Overcome Therapeutic Inertia Obstacles Now in T2DM (MOTION) study, to inform the development of strategies to address therapeutic inertia in T2DM. We present the results from focus groups with the following objectives: 1) understanding PwD and general practitioner/family practitioner (GPFP) determinants of behaviour related to treatment intensification using the Theoretical Domains Framework (TDF); and 2) identifying the sources of behaviours contributing to therapeutic inertia in T2DM, as proposed by the Behaviour Change Wheel (BCW). Two focus groups with PwD and 4 with GPFPs were conducted. Transcripts from the focus groups were coded independently by 2 investigators to identify themes, then mapped to TDF domains and linked using the BCW. RESULTS: For PwD, the most commonly coded TDF domains were intentions, goals, knowledge, beliefs about consequences and social influences. For GPFPs, the most common domains were intentions, environmental context and resources and social/professional role and identity. The BCW identified that PwD interventions should include reflective motivation, psychological capability and social opportunity; GPFP interventions should include physical opportunity, social opportunity and reflective motivation. CONCLUSIONS: Comprehensive strategies that target both PwD and GPFP barriers would encourage a more collaborative approach toward treatment intensification decisions and reducing therapeutic inertia.

Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review.

The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.

Dermatite atopique : trois cas cliniques Il était une fois...: Atopic dermatitis: three case reports.

Atopic dermatitis is a common condition and the clinical presentation is often classic. Yet management of the disease varies widely, not always taking into account the severity of the disease and its repercussions on the patient and his environment - personal or social. With on one side the resilience of the patient and on the other side a shortage of general practitioners or dermatologists, a lack of understanding in the professional or family environment, and clinical inertia, disease management is clearly insufficient. Like in all inflammatory dermatoses, the patient's and the physician's assessment and perception of the clinical severity or the deterioration of the quality of life often differ. These three clinical cases are real-life situations where the emphasis is on their history and not on therapeutic choices. © 2020 Elsevier Masson SAS. All rights reserved.

Glycated Hemoglobin Level Goal Achievement in Adults With Type 2 Diabetes in Canada: Still Room for Improvement.

OBJECTIVES: To describe the clinical histories and management of adults with type 2 diabetes who were not reaching their target glycated hemoglobin (A1C) levels and to identify barriers to achieving therapeutic goals. METHODS: Practice assessment surveys and practice audits were completed by 88 primary care physicians (PCPs) in the Diabetes Mellitus Assessment of Clinical managemenT In ONtario (DM-ACTION) program and by 56 diabetes specialists in the Diabetes Mellitus IMproving PAtient Care in our communiTies (DM-IMPACT) program. The DM-ACTION audit analyzed data from 1,173 adults with A1C levels ≥7.3% who were not prescribed insulin; the DM-IMPACT audit included 135 individuals with similar characteristics. RESULTS: Most PCPs (92%) and specialists (88%) stated that they typically recommend A1C levels of ≤7.0%; more than 90% indicated that they adjusted antihyperglycemic therapy within 3 months if suboptimal A1C targets endured. Among the DM-ACTION patients, the median A1C level was 7.8%; the median time between the last 2 A1C tests was 5 months; 58% were taking ≤2 noninsulin antihyperglycemic agents; and adjustment of glucose-lowering therapy was noted for only 56%. The corresponding values for the DM-IMPACT patients were 8.0%, 4 months, 43% and 68%, respectively. PCPs and specialists attributed patients' factors and patients' adherence as primary causes of poor achievement of guideline-recommended targets. PCPs perceived patients' factors as the predominant barrier to optimizing care, but the specialists believed that therapeutic inertia stems from a wide range and a varied combination of patient-centric factors. CONCLUSIONS: Type 2 diabetes remains a health-care challenge in Canada and globally. Primary care physicians and specialists attributed patients' factors as principal obstacles to optimal diabetes management. However, physician-associated therapeutic inertia may also be an important barrier to unmet therapeutic goals.

Reasons for non-intensification of treatment in people with type 2 diabetes receiving oral monotherapy: Outcomes from the prospective DIAttitude study.

OBJECTIVES: To describe the management of glucose-lowering agents in people with type 2 diabetes initially on oral monotherapy, cared for by French general practitioners, and to identify reasons underlying treatment non-intensification. METHODS: People with type 2 diabetes on oral monotherapy were recruited by general practitioners and followed-up over 12 months. Patient characteristics, HbA1c, and glucose-lowering treatments were recorded electronically. Management objectives and reasons for treatment non-intensification were solicited from the general practitioners. RESULTS: A total of 1212 patients were enrolled by 198 general practitioners; 937 patients (mean age 68 years) were treated with oral monotherapy, and 916 patients had at least two successive HbA1c values recorded. Of these, 390 patients (43%) had HbA1c≥6.5% on both occasions, and 164/390 (42%) had their treatment intensified. The 226 patients whose treatment was not intensified were older (69±11 years vs. 66±12 years, P=0.02) and had better glycaemic control at study inclusion (6.9%±0.6 vs. 7.3%±0.8, P<0.0001) than treatment intensified patients. Among uncontrolled patients, there were no differences in general practitioner treatment objectives at inclusion for treatment intensified and non-intensified patients; the main reason given by general practitioners for non-intensification was that the patient had an adequate HbA1c (66%). HbA1c did exceed the 6.5% target, but was less than 7.0% in 69% of cases. CONCLUSIONS: General practitioners showed a patient-centred approach to treatment, but clinical inertia was apparent for 31% of the uncontrolled patients.

[A specific questionnaire to evaluate therapeutic inertia in hypertensive patients: a pilot study]. / Évaluation de l'inertie thérapeutique chez des patients hypertendus à l'aide d'un questionnaire ciblé : étude pilote.

BACKGROUND: Therapeutic inertia (TI) is a recent concept still unknown by many physicians. In chronic diseases such as hypertension, it is defined as the tendency of physicians not to increase or change antihypertensive medications when the target blood pressure is not reached. Acting on TI could improve blood pressure control in France. METHOD: This was a single-center prospective pilot study conducted by hypertension specialist physicians at the University Cardio-Vascular Center in Lille (France). It was conducted between March and June 2011. Data was collected from 161 hypertensive patients (mean age: 61.64±11.18 years; 98 (60.9%) male; 75 secondary prevention patients). Each physician completed a questionnaire on therapeutic inertia. TI was defined as a consultation in which treatment change was indicated (systolic blood pressure [BP]≥140 and/or diastolic BP≥90mmHg in all patients), but did not occur, with absence of an adapted justification of this choice. We considered as an adapted justification: a white coat effect demonstrated by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring; scheduled reassessment of the BP by ABPM; recent change in antihypertensive treatment (less than 4 weeks); hospitalization needed for complete evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage in patients with grade 1 or 2 hypertension. Our study aimed to evaluate rates of TI, to identify factors associated with TI, and to test the TI questionnaire. RESULTS: Therapeutic inertia as defined in this study occurred in 11 consultations (8.3%) of the 133 hypertensive patients having uncontrolled BP above or equal to 140 and/or 90mmHg. Significant factors associated with TI were older age (Z=2.35, P<0.05) and sleep apnea syndrome (χ(2)=8.33, P<0.05). The absence of ambulatory blood pressure monitoring before the consultation (χ(2)=4.28, 0.1>P>0.05) and the number of consultations (Z=1.92, 0.1>P>0.05) exhibited a significant trend to be associated with TI. CONCLUSIONS: Although the rate of TI was low in our study conducted in a specialized center, a well-accepted definition of therapeutic inertia would be useful for further study. The feasibility of using the questionnaire tested with this study shows that this measurement tool could help physicians become more aware of TI, both in the hospital and primary care setting. Further multicenter studies are needed for validation.