Can J Diabetes 38 (2014) 290–291
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Editor’s Note
Therapeutic Inertia and Nihilism
Traditionally, the October issue of Canadian Journal of Diabetes, with its supplement containing the conference abstracts, is widely distributed to delegates attending the Joint Professional Conference of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism (CDA/CSEM). This year marks the 17th annual meeting, which continues to be the largest of its kind to be held in Canada. The joint conference is an ideal forum for presentation of the latest advances in the research, clinical management and prevention of diabetes and related conditions. Annual meetings are usually held by scholarly diabetes associations all over the world to exchange and disseminate the most current and topical scientific and clinical research and to promote collaboration and collegiality among diabetes investigators and practitioners. It would be of interest to look back and assess what has been accomplished with these annual meetings and to what extent they have influenced diabetes care and best practices in Canada. A hallmark of success is the increasing number of delegates attending the annual conference over the years. Until a few years ago, the conference was mainly a gathering of researchers, clinicians and educators involved in the care of people with diabetes. Another marker of success is the rising number of primary care practitioners attending the annual CDA/CSEM conference. The majority of people with diabetes in Canada are managed by family physicians, so attracting primary care practitioners to the conference is a top priority. In addition to symposia, lectures, workshops, debates, meet-the-professor sessions, and oral and poster presentations, a special symposium aimed at primary care practitioners was started by the conference organizing committee several years ago. This symposium was well received and became increasingly popular. This year, the primary care providers’ symposium will be an expanded from a half-day to a full-day event. Last year, the CDA/CSEM joined forces with the Canadian Cardiovascular Congress, the Canadian Stroke Network, the Heart and Stroke Foundation, and Hypertension Canada and held a 1-time Vascular 2013 Summit, which had a record attendance of several thousand delegates. The October 2013 issue of Canadian Journal of Diabetes was appropriately devoted to the cardiovascular complications of diabetes. Cardiovascular disease accounts for a large proportion of the excess and premature mortality related to diabetes (1). My early clinical experiences gained during my internship and residency training at the Joslin Clinic and the Harvard Medical School in the mid-1970s left me with an indelible memory of how devastating diabetes is. In an average week, I could count 10 or more patients admitted to the hospital for diabetic ketoacidosis, foot amputations for diabetic foot disease, and myocardial infarction. Many of these patients were quite young, not infrequently younger than 40 years of age. Fortunately, 1499-2671/$ – see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.08.003
the management of people with diabetes has improved substantially over the past 2 decades, with better glycemic control, which would predict a reduction of diabetes-related complications. We now see many fewer hospital admissions of patients with diabetes for myocardial infarction, stroke, diabetic ketoacidosis or foot amputation. Recent American data have confirmed a gradual but significant trend of decreasing prevalence of diabetes-related complications, with the largest relative declines in acute myocardial infarction (down 68%); death from hyperglycemic crisis (down 64%); followed by stroke and limb amputations, each of which decreased by about 50% (2). The greater decline in acute myocardial infarction and stroke rates can be attributed largely to a combination of advances in acute clinical care, care delivery and the widespread use of statins and antihypertensive drugs. The smallest decline was in end stage diabetic kidney disease (down 28%), which is the theme for this October issue. However, when taking into account the rising prevalence of diabetes, the burden of diabetic kidney disease persists and may actually increase in the future. I hope our readers will find the articles in this issue informative and clinically relevant to the prevention and management of diabetic kidney disease. There are many possible reasons for the small decline in diabetic kidney disease. Poor glycemic control is undoubtedly a major determinant of microvascular complications of diabetes, which include nephropathy, retinopathy and neuropathy. Even though there has been a gradual improvement in glycemic control over the past 2 decades, there remains a significant treatment gap in achieving the optimal glycemic control recommended by the evidence-based CDA clinical practice guidelines. Three crosssectional observational surveys of Canadian primary care physiciansdthe Diabetes in Canada Evaluation Study, made between 2002 and 2003; the Diabetes Registry to Improve Vascular Events study, made between 2005 and 2006; and the Diabetes Mellitus Status in Canada survey, made in 2012dall reported that only about half of the number of Canadian patients with type 2 diabetes reached the recommended A1C treatment target of 7% or lower (3–5). Less than 20% of the patients were on insulin therapy in all 3 studies. Primary care practitioners are generally reluctant to initiate insulin therapy in their patients despite suboptimal glycemic control with combination oral agents. In a multicentre international observational study of more than 17 000 patients with type 2 diabetes, the average A1C was 8.9% before insulin therapy was initiated (6). Data from the Canadian cohort (n¼1060) showed an identical baseline A1C value of 8.9% before insulin therapy. It is evident that the results of these surveys indicate a need for innovative strategies to encourage primary care practitioners to adopt and translate evidence-based clinical practice guidelines into everyday clinical care. It is important to note
Editor’s Note / Can J Diabetes 38 (2014) 290–291
that we need to understand the reasons for such therapeutic inertia, which is defined as providers’ failure to initiate or intensify therapy when treatment goals are unmet. This concept was first introduced in the management of hypertension, where its prevalence has been described as high as 75% (7). Why do clinicians fail to intensify treatment for chronic conditions such as diabetes? First, they overestimate how many of their patients are at therapeutic goals. Second, they may use “soft” reasoning to avoid intensification of therapy (physician perception without patient input that the patient will not accept more medications). Third, there may be a lack of education, training and organizational practices aimed at achieving therapeutic goals. Finally, therapeutic nihilism, a disbelief in the efficacy or value of glycemic and metabolic control in reducing the long-term complications of diabetes, may also lead to either appropriate inaction or inappropriate inertia. Overcoming therapeutic inertia and nihilism, in my opinion, will greatly improve diabetes care and reduce the attendant long-term complications such as diabetic kidney disease. What are the potential solutions to therapeutic inertia and nihilism? One approach is to conduct proper research studies to determine the principal drivers for therapeutic inertia and nihilism. Another approach is to develop symposia and workshops devoted to these topics at the annual CDA/CSEM joint conference. A third approach is to educate physicians as well as patients in the benefits of more aggressive glycemic control in reducing long-term complications. The annual conference, with its specific programs designed for primary care practitioners, would be an ideal forum for such educational initiatives. Using glycated hemoglobin as an indicator of
291
quality of healthcare and incorporating it into programs that pay providers for performance might be another option. Canadian Journal of Diabetes and I fully support and endorse the annual CDA/CSEM conference as a vital and essential forum for presenting and disseminating the latest advances in diabetes research, management and care. Seeking solutions for therapeutic inertia and nihilism should be a priority for both Canadian Journal of Diabetes and the annual CDA/CSEM conference. David C.W. Lau, MD, PhD, FRCPC Editor-in-Chief Canadian Journal of Diabetes E-mail address: [email protected] References 1. Lau DCW, Shen GX. Cardiovascular complications of diabetes. Can J Diabetes 2013;37:279–81. 2. Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990–2010. New Engl J Med 2014;370:1514–23. 3. Harris SB, Ekoe JM, Zdanowicz Y, et al. Glycemic control and morbidity in the Canadian primary care setting (results of the Diabetes in Canada Evaluation Study). Diab Res Clin Pract 2005;70:90–7. 4. Braga MF, Casanova A, Teoh H, et al. Poor achievement of guidelinesrecommended targets in type 2 diabetes: findings from a contemporary prospective cohort study. Int J Clin Pract 2012;66:457–64. 5. Leiter LA, Berard L, Bowering CK, et al. Type 2 diabetes mellitus management in Canada: Is it improving? Can J Diabetes 2013;37:82–9. 6. Khunti K, Damci T, Meneghini L, et al. Study of once daily levemir (SOLVE): Insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice. Diab Obes Metab 2012;14:654–61. 7. Okonofua EC, Simpson KN, Jesri A, et al. Therapeutic inertia is an impediment to achieving the Healthy People 2010 Blood Pressure Control goals. Hypertension 2006;47:345–51.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Editor’s Note
Therapeutic Inertia and Nihilism
Traditionally, the October issue of Canadian Journal of Diabetes, with its supplement containing the conference abstracts, is widely distributed to delegates attending the Joint Professional Conference of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism (CDA/CSEM). This year marks the 17th annual meeting, which continues to be the largest of its kind to be held in Canada. The joint conference is an ideal forum for presentation of the latest advances in the research, clinical management and prevention of diabetes and related conditions. Annual meetings are usually held by scholarly diabetes associations all over the world to exchange and disseminate the most current and topical scientific and clinical research and to promote collaboration and collegiality among diabetes investigators and practitioners. It would be of interest to look back and assess what has been accomplished with these annual meetings and to what extent they have influenced diabetes care and best practices in Canada. A hallmark of success is the increasing number of delegates attending the annual conference over the years. Until a few years ago, the conference was mainly a gathering of researchers, clinicians and educators involved in the care of people with diabetes. Another marker of success is the rising number of primary care practitioners attending the annual CDA/CSEM conference. The majority of people with diabetes in Canada are managed by family physicians, so attracting primary care practitioners to the conference is a top priority. In addition to symposia, lectures, workshops, debates, meet-the-professor sessions, and oral and poster presentations, a special symposium aimed at primary care practitioners was started by the conference organizing committee several years ago. This symposium was well received and became increasingly popular. This year, the primary care providers’ symposium will be an expanded from a half-day to a full-day event. Last year, the CDA/CSEM joined forces with the Canadian Cardiovascular Congress, the Canadian Stroke Network, the Heart and Stroke Foundation, and Hypertension Canada and held a 1-time Vascular 2013 Summit, which had a record attendance of several thousand delegates. The October 2013 issue of Canadian Journal of Diabetes was appropriately devoted to the cardiovascular complications of diabetes. Cardiovascular disease accounts for a large proportion of the excess and premature mortality related to diabetes (1). My early clinical experiences gained during my internship and residency training at the Joslin Clinic and the Harvard Medical School in the mid-1970s left me with an indelible memory of how devastating diabetes is. In an average week, I could count 10 or more patients admitted to the hospital for diabetic ketoacidosis, foot amputations for diabetic foot disease, and myocardial infarction. Many of these patients were quite young, not infrequently younger than 40 years of age. Fortunately, 1499-2671/$ – see front matter Ó 2014 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.08.003
the management of people with diabetes has improved substantially over the past 2 decades, with better glycemic control, which would predict a reduction of diabetes-related complications. We now see many fewer hospital admissions of patients with diabetes for myocardial infarction, stroke, diabetic ketoacidosis or foot amputation. Recent American data have confirmed a gradual but significant trend of decreasing prevalence of diabetes-related complications, with the largest relative declines in acute myocardial infarction (down 68%); death from hyperglycemic crisis (down 64%); followed by stroke and limb amputations, each of which decreased by about 50% (2). The greater decline in acute myocardial infarction and stroke rates can be attributed largely to a combination of advances in acute clinical care, care delivery and the widespread use of statins and antihypertensive drugs. The smallest decline was in end stage diabetic kidney disease (down 28%), which is the theme for this October issue. However, when taking into account the rising prevalence of diabetes, the burden of diabetic kidney disease persists and may actually increase in the future. I hope our readers will find the articles in this issue informative and clinically relevant to the prevention and management of diabetic kidney disease. There are many possible reasons for the small decline in diabetic kidney disease. Poor glycemic control is undoubtedly a major determinant of microvascular complications of diabetes, which include nephropathy, retinopathy and neuropathy. Even though there has been a gradual improvement in glycemic control over the past 2 decades, there remains a significant treatment gap in achieving the optimal glycemic control recommended by the evidence-based CDA clinical practice guidelines. Three crosssectional observational surveys of Canadian primary care physiciansdthe Diabetes in Canada Evaluation Study, made between 2002 and 2003; the Diabetes Registry to Improve Vascular Events study, made between 2005 and 2006; and the Diabetes Mellitus Status in Canada survey, made in 2012dall reported that only about half of the number of Canadian patients with type 2 diabetes reached the recommended A1C treatment target of 7% or lower (3–5). Less than 20% of the patients were on insulin therapy in all 3 studies. Primary care practitioners are generally reluctant to initiate insulin therapy in their patients despite suboptimal glycemic control with combination oral agents. In a multicentre international observational study of more than 17 000 patients with type 2 diabetes, the average A1C was 8.9% before insulin therapy was initiated (6). Data from the Canadian cohort (n¼1060) showed an identical baseline A1C value of 8.9% before insulin therapy. It is evident that the results of these surveys indicate a need for innovative strategies to encourage primary care practitioners to adopt and translate evidence-based clinical practice guidelines into everyday clinical care. It is important to note
Editor’s Note / Can J Diabetes 38 (2014) 290–291
that we need to understand the reasons for such therapeutic inertia, which is defined as providers’ failure to initiate or intensify therapy when treatment goals are unmet. This concept was first introduced in the management of hypertension, where its prevalence has been described as high as 75% (7). Why do clinicians fail to intensify treatment for chronic conditions such as diabetes? First, they overestimate how many of their patients are at therapeutic goals. Second, they may use “soft” reasoning to avoid intensification of therapy (physician perception without patient input that the patient will not accept more medications). Third, there may be a lack of education, training and organizational practices aimed at achieving therapeutic goals. Finally, therapeutic nihilism, a disbelief in the efficacy or value of glycemic and metabolic control in reducing the long-term complications of diabetes, may also lead to either appropriate inaction or inappropriate inertia. Overcoming therapeutic inertia and nihilism, in my opinion, will greatly improve diabetes care and reduce the attendant long-term complications such as diabetic kidney disease. What are the potential solutions to therapeutic inertia and nihilism? One approach is to conduct proper research studies to determine the principal drivers for therapeutic inertia and nihilism. Another approach is to develop symposia and workshops devoted to these topics at the annual CDA/CSEM joint conference. A third approach is to educate physicians as well as patients in the benefits of more aggressive glycemic control in reducing long-term complications. The annual conference, with its specific programs designed for primary care practitioners, would be an ideal forum for such educational initiatives. Using glycated hemoglobin as an indicator of
291
quality of healthcare and incorporating it into programs that pay providers for performance might be another option. Canadian Journal of Diabetes and I fully support and endorse the annual CDA/CSEM conference as a vital and essential forum for presenting and disseminating the latest advances in diabetes research, management and care. Seeking solutions for therapeutic inertia and nihilism should be a priority for both Canadian Journal of Diabetes and the annual CDA/CSEM conference. David C.W. Lau, MD, PhD, FRCPC Editor-in-Chief Canadian Journal of Diabetes E-mail address: [email protected] References 1. Lau DCW, Shen GX. Cardiovascular complications of diabetes. Can J Diabetes 2013;37:279–81. 2. Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990–2010. New Engl J Med 2014;370:1514–23. 3. Harris SB, Ekoe JM, Zdanowicz Y, et al. Glycemic control and morbidity in the Canadian primary care setting (results of the Diabetes in Canada Evaluation Study). Diab Res Clin Pract 2005;70:90–7. 4. Braga MF, Casanova A, Teoh H, et al. Poor achievement of guidelinesrecommended targets in type 2 diabetes: findings from a contemporary prospective cohort study. Int J Clin Pract 2012;66:457–64. 5. Leiter LA, Berard L, Bowering CK, et al. Type 2 diabetes mellitus management in Canada: Is it improving? Can J Diabetes 2013;37:82–9. 6. Khunti K, Damci T, Meneghini L, et al. Study of once daily levemir (SOLVE): Insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice. Diab Obes Metab 2012;14:654–61. 7. Okonofua EC, Simpson KN, Jesri A, et al. Therapeutic inertia is an impediment to achieving the Healthy People 2010 Blood Pressure Control goals. Hypertension 2006;47:345–51.
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