Effect of Clinical Inertia on Diabetes Complications among Individuals with Type 2 Diabetes: A Retrospective Cohort Study

Background and Objectives: Clinical inertia is a key obstacle that leads to suboptimal care in patients with type 2 diabetes mellitus (T2DM). It can occur at any stage of T2DM treatment. However, the effect of clinical inertia on diabetes complications has not been studied sufficiently. This study aimed to evaluate the effect of clinical inertia on the risk of diabetes complications among patients with T2DM. Materials and Methods: A retrospective cohort study was conducted at a tertiary teaching hospital in Thailand between 2011 and 2017. Outpatients with T2DM, aged 40–65 years, presenting an HbA1c greater than 7% were included in this study. Clinical inertia was identified when patients did not get treatment intensification at the index date and a subsequent prescription. The association between clinical inertia and diabetes complications, including a composite of macrovascular complications and a composite of microvascular complications, was determined using a Cox proportional hazard model. Propensity score methods were applied, to control confounding by indication. Results: Of 686 patients with T2DM, 165 (24.0%) experienced clinical inertia. Baseline low-density lipoprotein cholesterol, blood pressure, body mass index, the estimated glomerular filtration rate, and medication between the two groups did not differ significantly. Our study found that clinical inertia was associated with a significantly increased risk of diabetic nephropathy (adjusted HR 1.51, 95% CI 1.01–2.27). The results remained the same as when using propensity score methods. According to the post hoc analysis, lowering the HbA1c levels by 1% results in a significant decrease in the rate of diabetic complications (adjusted HR 0.92, 95% CI 0.86–0.99), the composite of microvascular complications (adjusted HR 0.91, 95%CI 0.84–0.98) and diabetic nephropathy (adjusted HR 0.89, 95% CI 0.80–0.98). Conclusions: Our results demonstrated a significant effect of clinical inertia on diabetic nephropathy. Patients with an HbA1c level over the target range should have their medication intensified to reduce the risk of diabetic nephropathy.

130 Impact of Low-Dose High-Frequency in situ Simulation on Inpatient Diabetes Management: A Pilot Study

Even in the presence of established institutional guidelines, failure of compliance by the clinical teams plays an important role in the control of diabetes. The identified gaps include contextual and biomedical knowledge, attitudes, clinical inertia, confidence and familiarity with existing hospital resources and guidelines with regards to hospital diabetes care We wanted to demonstrate the efficacy of low-dose high-frequency The exercise was a 15-minute session, delivered during working hours to individual nurses. This consisted of a 5-minute scenario, involving a standardized patient followed by a 10-minute debrief. Modified Diamond-model debrief with an advocacy-inquiry model was used by the debriefer, a trained fellow in simulation, and overseen by an expert. The scripted scenario involved a patient with Diabetic Ketoacidosis (DKA), with learning outcomes of recognizing DKA, managing the patient and adhering to the institutional guidelines including management of hypoglycaemia. The scenario was individualized based on the roles of the participants. Pre- and post-questionnaires were given to the participants. The simulation was repeated twice in the second week and once in the third week.This mixed-method study was conducted in a UK teaching hospital, in a ward designated for patients with diabetes, as a part of a quality improvement programme. In the first week, patients with diabetes, admitted for DKA, were chosen and their blood sugar recordings, dysglycaemic episodes and adherence to guidelines were noted. Every week data were collected as in the first week. GNU pspp 1.0.1 [version 3] free software was used. The confidence scores were given as mean and standard deviation with confidence interval (CI) of 98.75%. A p-value of <0.0125 was considered significant based on the number of data points.The Dysglycemic episodes and protocol adherence from medical recordsConsidering the T2 (increased recognition of diabetic emergencies and adherence to protocol) and T3 (improved patient outcomes) outcomes, the methodology was recommended as a modality of training the nursing staff involved in inpatient care of patients with diabetes. Future programmes including multi-disciplinary teams, to explore teamwork and communication, are planned.

The management of type 2 diabetes before, during and after Covid-19 infection: what is the evidence?

Patients with Covid-19 place new challenges on the management of type 2 diabetes, including the questions of whether glucose-lowering therapy should be adjusted during infection and how to manage a return to normal care after resolution of Covid-19 symptoms. Due to the sudden onset of the pandemic, physicians have by necessity made such important clinical decisions in the absence of robust evidence or consistent guidelines. The risk to patients is compounded by the prevalence of cardiovascular disease in this population, which alongside diabetes is a major risk factor for severe disease and mortality in Covid-19. We convened as experts from the Central and Eastern European region to consider what advice we can provide in the setting of type 2 diabetes and Covid-19, considering the evidence before, during and after infection. We review recommendations that have been published to date, and consider the best available—but currently limited—evidence from large observational studies and the DARE-19 randomized control trial. Notably, we find a lack of guidance on restarting patients on optimal antidiabetic therapy after recovering from Covid-19, and suggest that this may provide an opportunity to optimize treatment and counter clinical inertia that predates the pandemic. Furthermore, we emphasize that optimization applies not only to glycaemic control, but other factors such as cardiorenal protection. While we look forward to the emergence of new evidence that we hope will address these gaps, in the interim we provide a perspective, based on our collective clinical experience, on how best to manage glucose-lowering therapy as patients with Covid-19 recover from their disease and return to normal care.