Doctors Are Urged to Be More Aggressive In Managing High Sugar, Blood Pressure
By David Brown
Washington Post Staff Writer
Sunday, June 11, 2006
Millions of diabetics are being inadequately treated because of "clinical inertia" on the part of physicians who fail to push doses of diabetes drugs, insulin and blood pressure medications to levels that can best protect patients from the disease and its complications.
That is the conclusion of four studies presented yesterday at the American Diabetes Association's scientific conference being held in the District.
Physicians know that high blood sugar and high blood pressure are dangerous, and appear to understand that certain people -- such as men, the elderly and blacks -- are at higher-than-average risk of problems. But they simply do not act on that knowledge quickly or aggressively, the studies showed.
"There is a lack of physician action in the face of abnormal findings," said Nathaniel G. Clark, a physician and vice president of the association. "We are simply not achieving what we need to in clinical diabetes care."
The studies are the latest addition to the growing body of evidence that millions of Americans get less than optimal health care even when they are insured, well educated and middle class. The findings are especially troubling because they involve a disease -- Type 2 diabetes (once called "adult-onset") -- that affects 21 million Americans and whose prevalence is increasing at the rate of 8 percent a year.
Unanswered by the studies is what practitioners are thinking when they fail to intensify treatment. At a news conference Friday, the first day of the meeting, the researchers speculated that many factors are at work.
Among them are: the difficulty of hitting treatment goals when doctors do try; the time and effort required to start a patient on a new drug; the reluctance of many patients to take more pills or shots; the reality that elevated blood sugar and blood pressure rarely cause symptoms; the distraction of minor but immediate problems, such as sore throats, that patients tend to focus on during doctor visits; and a human tendency to be satisfied with results that are "close enough."
While not dismissing any of those, the researchers said they do not add up to an excuse.
"I think what's important is that these obstacles are overestimated, and physicians really should be doing much more than they are doing now," said Alexander Turchin, an endocrinologist at Brigham and Women's Hospital in Boston, who led a study that found doctors responded to high blood pressure in diabetics less than half as often as they should have.
Guidelines suggest that diabetics should keep their blood pressure below 130/80, because the disease puts them at markedly higher risk of heart attacks. Turchin and his colleagues examined the records of about 12,100 patients treated by more than 500 Harvard-affiliated physicians from 2000 to 2005. The patients were 63 years old on average. About 40 percent were non-white, and slightly more than half were female.
The patients' blood pressure was recorded in two-thirds of the clinic notes, and in 57 percent of those encounters, the readings were above the recommended target. But in only 21 percent of the visits did the doctor do anything about it.
However, the higher the blood pressure, the greater the likelihood the doctor would intervene, the study found. Physicians were also 15 percent more likely to increase the dose of blood pressure medicine or start a new one for a non-white patient or a man -- two groups of diabetics who are at higher-than-usual risk of heart attacks.
Physicians still in training were 25 percent more likely to "intensify" treatment than those out in practice, the researchers found. Comparing physicians who were 10 years apart in age, they also found that the older ones were 14 percent less likely to step up treatment.
"While the physicians do react to increased risk, they clearly are not reacting enough," Turchin said.
In another study, Shari Bolen of Johns Hopkins University School of Medicine examined the records of 254 people with diabetes and hypertension in a managed-care plan for government employees.
From 1999 through 2001, there were about 1,400 visits to primary-care physicians in which the patient had blood pressure that was too high. In only 12 percent of visits, however, did the doctor intensify treatment. The physician was twice as likely to act if the patient came in for a routine visit rather than for an immediate problem.
Ironically, patients who were also seeing a heart specialist were less likely to have their dosages increased than if they were under the care of a primary-care doctor only.
"Each may think the other is taking care of the hypertension," Bolen said.
A third study looked at what happened to about 9,500 people after they were first prescribed a diabetes drug. All were treated in a national managed-care plan.
The researchers looked at how doctors reacted to readings on a test called "hemoglobin A1C," which physicians use to judge a patient's blood-sugar levels over a prolonged period -- two or three months. The results are expressed as a percentage -- the higher the average blood sugar, the higher the percentage. The target should be no more than 7 percent, according to the Diabetes Association.
At the start of treatment, the average for patients in the study was 8.4 percent -- no surprise. However, it took an average of 240 days before their doctors intensified treatment, and by then the average reading was higher than at the outset. More than 60 percent of the patients were approaching 10 percent, a markedly high reading. The study was conducted by Craig A. Plauschinat, a pharmacist with Novartis Pharmaceuticals Corp.
In the fourth study, Steve Gough, a diabetologist at Britain's University of Birmingham, looked at the most recent hemoglobin A1C levels of about 3,700 diabetic patients in Germany and England who were taking insulin. The average was 8.4 percent for the Germans and 8.1 percent for the Britons -- both abnormal. Nearly one in five had levels above 10 percent.
About half of patients with Type 2 diabetes will ultimately need to switch from pills to insulin injections, a big step. This study suggested that once it is made, physicians let up.
"Patients and doctors seem to get stuck at one injection a day," Gough said. "They seem not to be able to progress" to more intensive treatment.
In Britain's national health system, Gough said, physicians are starting to receive points for following specified guidelines, such as routinely prescribing cholesterol-lowering drugs to diabetics, advising them to take a daily aspirin or reaching blood-pressure goals.
A practitioner who accumulates enough points gets a cash bonus. The program has increased the percentage of patients hitting the recommended targets, Gough said, adding:
"They are doing what they are paid for, but it's extra money, and that's the reality of it."
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