What doctors' practices affect poor diabetic control in their patients?

Physician Practices Affecting Poor Diabetic Control in Patients

Clinical inertia is the primary physician practice affecting poor diabetic control, occurring when providers fail to intensify treatment despite patients not meeting glycemic targets. This practice is prevalent in diabetes management, with over 50% of patients with poor glycemic control not receiving appropriate medication intensification within reasonable timeframes 1.

Key Physician Practices Contributing to Poor Diabetic Control

Clinical Inertia

• Less than 50% of patients with high A1c levels have intensification of their medications, regardless of physician specialty 2
• Primary care physicians demonstrate more clinical inertia than specialists, with only 37.4% intensifying treatment compared to 45.1% of specialists when faced with elevated A1c levels 2
• Specialists are more aggressive with insulin initiation than primary care physicians, which may contribute to better glycemic control in specialist-managed patients 2

Inadequate Patient Education

• Only 10.2% of primary care physicians recognize the importance of regular exercise for diabetes management 3
• Merely 4.5% of physicians acknowledge the importance of patient education in diabetes management 3
• Many healthcare providers fail to refer patients to specialists for education, with fewer than 25% of physicians routinely referring patients to dietitians or health educators 4
• Most diabetic patients report dissatisfaction with the educational role of primary care physicians 3

Poor Team-Based Care Implementation

• Successful diabetes management requires a dedicated interprofessional team including physicians, nurses, diabetes educators, dietitians, pharmacists, and other healthcare professionals 1
• Lack of team communication and administrative buy-in to promote the roles of medical directors, nursing directors, and consultant pharmacists contributes to poor control 1
• Facilities often lack diabetes-specific treatment algorithms and protocols for blood glucose management 1

Cognitive Biases and Misperceptions

• Physicians routinely underestimate the need to intensify therapy, with studies showing misperceptions of control in 41% of cases despite most patients being obese 1
• Healthcare providers overestimate the care they provide, believing 75% of patients receive guideline-recommended medications when only 65% actually do 1
• Providers overestimate the proportion of patients achieving target blood pressure levels (68% perceived versus 43% actual) 1

Guideline Implementation Barriers

• Many physicians doubt the credibility of evidence or believe that guideline benefits don't outweigh risks 1
• Some providers perceive that guidelines reduce their autonomy or undermine the provider-patient relationship 1
• Guidelines are often criticized for being overly simplified or not applicable to individual patients 1
• Across multiple surveys, physicians report guidelines are not easy to use (17%), inconvenient (11%), cumbersome (10%), or confusing (4.5%) 1

Specific Practices in Different Healthcare Settings

Long-Term Care Facilities

• Inadequate review of glucose logs and trends in long-term care facilities 1
• Lack of facility-specific diabetes treatment algorithms for blood glucose management 1
• Excessive reliance on sliding-scale insulin (SSI) rather than basal-bolus regimens 1
• Inappropriate dosing or timing of insulin administration 1
• Failure to advance therapy in a timely, step-wise manner 1

Hospital Settings

• Poor self-management education during hospitalization, with many facilities failing to provide even basic "survival skills" education before discharge 1
• Continued use of outdated "ADA diet" terminology and calorie-based meal plans rather than individualized nutrition therapy 1
• Inadequate involvement of appropriately trained specialists or specialty teams, which can lead to longer hospital stays and poorer outcomes 1

Strategies to Overcome Physician-Related Barriers

Addressing Clinical Inertia

• Implement standardized order sets for scheduled and correction-dose insulin to reduce reliance on sliding-scale management 1
• Develop clear protocols for subcutaneous insulin therapy that effectively achieve glycemic targets 1
• Encourage physicians to exercise professional judgment in patient management rather than rigid adherence to guidelines that may not fit all patients 1

Improving Patient Education

• Focus on teaching patients about hypoglycemia recognition and management, particularly for those at risk for disruptive hypoglycemia 1
• Regularly discuss the risk of driving with low blood glucose with patients who drive 1
• Review blood glucose logs during clinical visits and question patients about symptoms associated with high or low glucose levels 1

Enhancing Team-Based Care

• Develop multidisciplinary support for using insulin therapy appropriately 1
• Ensure regular communication between ophthalmologists and general physicians regarding ocular findings 1
• Implement referrals for counseling, rehabilitative, or social services for patients whose conditions fail to respond to treatment 1

Common Pitfalls and How to Avoid Them

• Focusing only on medication adjustments without addressing underlying adherence issues is a common pitfall in managing poor control 5
• Overlooking psychosocial factors that may be driving non-adherence can significantly impact diabetes management 5
• Setting overly aggressive targets in patients at high risk for hypoglycemia can lead to adverse outcomes 5
• Failing to consider health literacy and numeracy when providing diabetes education limits effectiveness 5
• Not recognizing the impact of social determinants of health on diabetes management prevents comprehensive care 5