Improving Diabetes Care: Overcoming Clinical Inertia and Improving Outcomes Through Targeted, Automatic Electronic Consults

Diabetes is a challenging disease for patients to manage, and it also can be tough for their doctors, given that most ongoing or routine care and evaluation after diagnosis is handled by primary care physicians and not endocrinologists.

Diabetes also poses significant challenges to insurance providers and entities like the U.S. Centers for Medicare and Medicaid. Indeed, more than 30 million Americans live with some form of diabetes. The upward trajectory of diabetes in the U.S. continues. A staggering percentage of total Medicare spending annually – approximately 25% – goes toward the care of people with diabetes because the vast majority of the individuals cannot achieve the clinically necessary benchmarks for glucose control and other biomarkers, including lipids and blood pressure levels.

“Uncontrolled or poorly controlled diabetes can spiral a person’s health and long-term outcomes downward rapidly,” says Esra Karslioglu French, MD, MBA, ECNU, clinical associate professor of Medicine and Endocrine medical director in the UPMC and University of Pittsburgh Division of Endocrinology and Metabolism. "And once significant comorbidities like heart disease, kidney disease, retinopathy, and the like set in, they are generally not reversible and are highly disruptive to patient health, lifespan, and quality of life. Plus, they are expensive to treat. So, while we are focused on helping individuals maintain healthy glucose levels through various means, we're trying to mitigate these other terrible downstream detrimental effects that arise when diabetes is not optimally controlled."

For Dr. Karslioglu French, if a patient newly diagnosed with diabetes is not on the path toward optimal control after six months, or if an existing patient is experiencing difficulties in glucose control, immediate intervention should be the standard of care, be it the introduction of new medications or tools like continuous glucose monitoring and insulin pumps and more intensive education and coaching. However, this is not the path most patients experiencing difficulties managing their disease end up on.

The Complexities of Diabetes Care

Diabetes is a complex and multifaceted disease to study and treat. Beyond the disease causes and pathophysiology, there are individual and population effects, health care disparities of one variety or another, the expense of medications, and insufficient specialists to manage the burgeoning population of chronic disease care. One such complexity that can often arise and impede optimal diabetes management is what is known as clinical inertia.

On the provider side of the equation, clinical inertia comes into play when providers hesitate or delay intensifying treatment or changing therapeutic plans of care when clinically necessary. It can and does occur in the primary care setting for many reasons, not the least of which is the sheer number of patients and types of care that most primary care practitioners are juggling day-to-day.

However, leveraging digital health interventions, specifically Targeted Automatic eConsults (TACos), is a potentially effective remedy to clinical inertia.

New Study Shows Effectiveness of TACo Intervention

TACos, a type of electronic consultation (eConsult), uses electronic health record (EHR) data to proactively identify patients at risk for poor diabetes outcomes and the development of detrimental comorbidities and suggests unsolicited specialist recommendations to primary care providers (PCPs) immediately before a regularly scheduled health care visit.

The use of TACos aims to facilitate the efficient utilization of specialist resources and encourages shared decision-making between patients and providers. Importantly, TACos are designed to help PCPs overcome clinical inertia by giving them access to specialist advice without delays, thereby speeding up the process of treatment intensification.

In a study published in June 2023 in the journal Population Health Management, Dr. Karslioglu French and colleagues from the UPMC Insurances Services Division, and members of the UPMC Center for High-Value Health Care, outline their development of a TACos intervention pilot project targeted at adult patients with uncontrolled type 2 diabetes.

The analysis included 196 individuals receiving TACos, matched with 392 control participants. Results showed TACos recommendations were enacted 65% of the time.

Dr. Karslioglu French and colleagues utilized a predictive model created by UPMC Clinical Analytics Department to identify high risk patients. Providers in the Division of Endocrinology and Metabolism then reviewed the individual's medical history to devise specific recommended interventions, which were transmitted electronically to the primary care provider just before the patient's upcoming scheduled visit.

“The predictive model is a machine learning algorithm which helps us identify patients with HbA1c levels greater than 8%, and who are likely to continue to have poor diabetes control over time,” says Dr. Karslioglu French.

After six months, the TACos intervention group showed a significantly greater median percent change in HbA1c (-10.9%) compared to controls (-10.2%), and lower median total costs (by 7.9%). Compared to the controls, individuals within the intervention group who implemented the TACos recommendations showed a significantly greater median percent change in HbA1c (19.5%), though total costs were not significantly different.

"Our study found that although drug costs increased in the TACos patient cohort relative to the control group, total median costs were lower, " says Dr. Karslioglu French. "This is also another indicator that the interventional approach successfully moved patients into new or alternative medications that may be more effective in helping them achieve glucose control.”

These findings suggest TACos interventions can address clinical inertia in primary care, improve diabetes management control, and potentially reduce health care costs.

TACos can help to identify high-risk patients rapidly, spread out the efficient use of endocrinologists who are in short supply around the country, and likely allow such an intervention to work across or in geographic locations with fewer resources.

These interventions can also facilitate timely treatment and support PCP decision-making while encouraging evidence-based practices.

Reference

Karslioglu French E, Kanter J, Winger ME, Williams K, Grumski T, Schuster J, Beckjord E. A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes. Popul Health Manag. 2023 Jun; 26(3): 168-176