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Research ArticleOriginal Research

Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin

Michael L. Parchman, Jacqueline A. Pugh, Raquel L. Romero and Krista W. Bowers
The Annals of Family Medicine May 2007, 5 (3) 196-201; DOI: https://doi.org/10.1370/afm.679
Michael L. Parchman
MD, MPH
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Jacqueline A. Pugh
MD
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Raquel L. Romero
MD
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Krista W. Bowers
MD
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    Figure 1.

    Percentage of patients with a change in medication, by encounter length and presence of patient concerns.

    Note: χ2 across Patient concern: 7.26 (P =.03); χ2 across No patient concern: 6.93 (P =.03).

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    Table 1.

    Characteristics of Patients and Encounters (N=177)

    CharacteristicMean (SD) or %
    Hemoglobin A1c=glycosylated hemoglobin.
    Age, years59.0 (13.3)
    Female, %51.3
    Hispanic, %59.2
    Hemoglobin A1c level
        >7.0%55.4,
        >8.0%34.5
    Length of encounter, minutes17.0 (8.4)
    Number of patient concerns2.0 (1.9)
    Encounters with a change in hypoglycemic medication, %
        All26.7
        With hemoglobin A1c level >7%35.6
        With hemoglobin A1c level >8%42.9
        With hemoglobin A1c level >9%46.4
    Days to next scheduled appointment60.9 (43.2)
    • View popup
    Table 2.

    Changes in Medication by Patient and Encounter Characteristics if Hemoglobin A1c Value Was Greater Than 7% (n = 98)

    CharacteristicChange in Medication Mean (SD) or %No Change in Medication Mean (SD) or %P Value
    Hemoglobin A1c=glycosylated hemoglobin.
    Patient characteristics
        Age, years57.5 (13.2)56.7 (13.5).76
        Female, %54.950.0.55
        Hispanic, %60.859.6.88
        Number of comorbidities4.8 (2.2)4.3 (1.9).22
        Hemoglobin A1c, %8.6 (2.1)7.3 (1.7)<.001
        Previous hemoglobin A1c level worse, %51.550.9.95
        Number of long-term medications7.09 (3.14)5.51 (2.92).02
    Encounter characteristics
        Number of patient concerns1.5 (1.3)2.4 (2.1).04
        Number of topics discussed by physician13.4 (4.49)11.3 (5.05).05
        Length of encounter, minutes19.4 (7.2)15.4 (7.8).02
        Number of days since last measured hemoglobin A1c70.8 (94.8)110.2 (170.5).07
    Percentage of encounter devoted to:
        Discussing nutrition5.23 (6.25)2.91 (4.76).07
        Discussing exercise1.50 (2.24)1.71 (3.20).77
        Discussing medication compliance7.47 (6.26)7.79 (6.09).83
    Percentage of encounter time until:
        Evaluation/feedback of test results48 (0.29)0.62 (0.80).44
        Discussion of planning treatment74 (0.28)0.80 (0.43).57
    • View popup
    Table 3.

    Predictors of Change in Medication

    If A1c >7% (n=98)If A1c >8% (n=61)
    PredictorOdds Ratio95% CIOdds Ratio95% CI
    CI=confidence interval; hemoglobin A1c=glycosylated hemoglobin.
    Number of patient concerns0.510.40–0.650.520.33–0.83
    Number of clinician topics1.020.93–1.121.000.90–1.10
    Length of encounter in minutes1.081.00–1.171.000.93–1.09
    Most recent hemoglobin A1c value1.110.83–1.481.150.77–1.74
    Number of long-term medications1.100.93–1.311.030.86–1.24
    Days since last hemoglobin A1c1.000.99–1.001.001.00–1.00

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  • The Article in Brief

    Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin

    Michael L. Parchman, MD, MPH , and colleagues

    Background Medication plays a key role in controlling blood sugars in diabetes patients. This study examines two possible reasons why primary care doctors might not change the medication of diabetes patients whose blood sugar is not well controlled: "clinical inertia" (recognizing but not acting on a medical problem), and "competing demands" (the need to address several medical problems, patient concerns, and preventive health measures in the limited time of a doctor visit).

    What This Study Found Primary care doctors address and prioritize many medical issues during patient visits. As the number of medical issues raised by a patient with high blood sugar goes up, the likelihood of a change in their medication goes down. Compared with other doctor visits, those in which diabetes medication is changed are longer, and the patient has fewer medical concerns but a higher blood sugar. Doctors spend the same amount of time discussing self-care measures with patients who have high blood sugars, regardless of whether they change the medication.

    Implications

    • The ability to treat multiple conditions is a strength of primary care. Because multiple conditions present competing demands, the patient and doctor must set goals and priorities during their visits.
    • Studies using the term "clinical inertia" usually focus only on diabetes care and not the patients� other health care needs. As a result, approaches to diabetes care based on clinical inertia are likely to be ineffective.
    • The concept of competing demands better describes the diabetes patient�s primary care visit than the concept of clinical inertia.
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The Annals of Family Medicine: 5 (3)
The Annals of Family Medicine: 5 (3)
Vol. 5, Issue 3
1 May 2007
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Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin
Michael L. Parchman, Jacqueline A. Pugh, Raquel L. Romero, Krista W. Bowers
The Annals of Family Medicine May 2007, 5 (3) 196-201; DOI: 10.1370/afm.679

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Competing Demands or Clinical Inertia: The Case of Elevated Glycosylated Hemoglobin
Michael L. Parchman, Jacqueline A. Pugh, Raquel L. Romero, Krista W. Bowers
The Annals of Family Medicine May 2007, 5 (3) 196-201; DOI: 10.1370/afm.679
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