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Provider Behavior and Treatment Intensification in Diabetes Care
Helaine E. Resnick, PhD, MPH; and Michael E. Chernew, PhD

Provider Behavior and Treatment Intensification in Diabetes Care

Helaine E. Resnick, PhD, MPH; and Michael E. Chernew, PhD
The authors undertook a literature search on treatment intensification in diabetes care to identify relevant research that has been published since 2000.

Objectives: To review the literature relating to treatment intensification in diabetes care and provider traits.

Study Design: Literature review and synthesis.

Methods: A literature search was conducted using PubMed and Google Scholar for papers published in or after 2000 that examined treatment intensification in diabetes care. Results from the searches were combined with a conventional Google search and a supplemental review of papers that were identified from reference lists of identified studies.  

Results: The majority of papers that were identified used administrative data to assess treatment intensification, and these showed that individuals with diabetes and elevated glucose frequently do not receive timely changes in therapy in response to hyperglycemia. Relatively few reports address provider and practice characteristics associated with these treatment decisions. Many of the studies focusing on the relationship between provider traits and treatment intensification are based on small studies in a limited number of practices.  Factors such as practice size, location, or experience in treating patients with diabetes were often not addressed in the literature despite their potentially far-reaching impact on treatment.

Conclusions: Our literature search on treatment intensification in diabetes care shows that the majority of papers using administrative data to assess treatment intensification suggest that care is often discordant with recommended guidelines. However, there is a dearth of literature based on large databases examining physician and practice traits related to this discordance. Better understanding physician behavior and practice traits associated with treatment intensification may permit greater targeting of interventions aimed at improving care.

Am J Manag Care. 2015;21(6):e399-e404
Take-Away Points
Our literature search on treatment intensification in diabetes care shows that the vast majority of papers using administrative data to assess treatment intensification suggest that care is often discordant with recommended guidelines. However, there is a dearth of literature using large databases that examine physician and practice traits related to this discordance.
  • There is a great deal of evidence indicating failure to intensify treatment in diabetes care, but little is known about physician and practice traits that influence treatment decisions.
  • Better understanding physician behavior and practice traits associated with treatment intensification may facilitate targeting of interventions aimed at improving care.
Clinical practice guidelines for the management of people with diabetes provide direction to clinicians on a number of key issues, including targets for glycemic (glucose) control and when to intensify an existing treatment regimen that is not meeting target.1 Despite the availability of these detailed guidelines, there is ample evidence supporting the idea that many people with diabetes have blood glucose levels and other cardiovascular risk factors that are above recommended levels,2 leading to poor clinical outcomes and avoidable health costs. A wealth of research finds that diabetes is undertreated, with many individuals with diabetes going undiagnosed, diagnosed but untreated, or treated but not adherent.3-5 Equally important, a great deal of research shows that despite access to healthcare, these individuals with elevated glucose—in both the inpatient and outpatient settings—do not receive timely changes in therapy in response to documented hyperglycemia.6-10 For example, a study of administrative data describing 16,800 patients with diabetes at 13 Veterans Administration medical centers showed that despite an average of 8.8 annual visits, glycated hemoglobin (A1C)—a key indicator of glycemic control—did not improve, with nearly 40% of patients having values of 8% or higher, which is well above normal. Intensification of diabetes treatment occurred in only 9.8% of all visits in this study.11

Against this backdrop, obvious questions arise regarding why healthcare providers do not consistently intensify treatment of their patients with diabetes in situations where there is a clear indication that glucose, or other risk factors such as blood pressure and lipid measures, are inconsistent with practice guidelines. These questions are particularly salient as Medicare, Medicaid, and other payers pursue delivery reforms (eg, accountable care organizations and medical homes) intended to improve clinical and cost results through better management of chronic illnesses. A recent report by the American Diabetes Association estimated that in 2012, the total costs associated with diabetes topped $245 billion, with 43% of total costs going to inpatient care, suggesting that there may be ample opportunities for savings associated with better care.12 Specifically, achieving better performance under new health system incentives—such as those intended to reduce certain inpatient readmissions—may depend in part on improved chronic care management.

A seminal report by Phillips13 led to numerous studies focusing on the role of “clinical inertia” in healthcare delivery, including diabetes care. As conceptualized by Phillips et al, clinical inertia is the “failure of healthcare providers to initiate or intensify treatment when indicated.” This failure is postulated to be fueled by a combination of provider, patient, and organizational factors.14 The Phillips paper was a driving force behind the publication of a large body of literature whose findings suggested that the gap between what is recommended in diabetes care and what is actually acted upon during a clinical encounter reflects widespread deficiencies in quality of care. This line of thinking equates lack of action with lack of quality. It goes on to argue that these apparent deficiencies result in a considerable amount of potentially avoidable morbidity and mortality in an ever-increasing diabetic population, and that aggressive action is needed to encourage physicians to engage in prescribing behaviors that are more effective in helping patients achieve standard clinical targets. One report even likens failure to intensify treatment to a medical error.15

In contrast, Parchman et al offer an opposing viewpoint16 in which the “competing demands” that characterize routine clinical practice—particularly with older, medically complex patients—influence the likelihood of changes in therapy. In this line of thinking, physicians and patients prioritize problems, address the most pressing ones, and defer action on lower priority problems to future encounters. In an environment in which clinicians are being encouraged to engage in patient-centered decision making,17 this type of collaborative prioritization can be viewed as both reasonable and justifiable, a concept that has been acknowledged elsewhere.18

Regardless of which model one ascribes to, if case-mix is adequately adjusted for, intensification care should reflect patient traits, not provider, provider group, or delivery system traits. The purpose of this literature review and synthesis is to assess what is known about the relationship between provider, practice group, or system traits and treatment intensification. Moreover, we are interested in how much of our current understanding is based on studies of a few practice settings as opposed to analyses of large databases that might capture the general patterns of care across the country. Understanding these relationships can help with the design and targeting of interventions in the new delivery models, emphasizing systems of care and improved chronic care management.


To maximize application of this review to the current clinical landscape, we limited our search to material that was published from the year 2000 onward. We identified combinations of search terms based on an initial review of recent reports on clinical inertia in diabetes care; these terms repeat with great frequency in many of the published reports. Articles were identified if they met any of these criteria. The search combinations were: “clinical inertia and type 2 diabetes,” “clinical inertia and glycemic control,” “clinical inertia and glucose control,” “clinical inertia and HbA1c,” “under treatment and type 2 diabetes,” “treatment intensification and type 2 diabetes,” “non-treatment and type 2 diabetes,” and “clinical targets and type 2 diabetes.” In addition to these PubMed searches, a Google Scholar search was conducted using the terms “clinical inertia” and “type 2 diabetes” and a conventional Google search was conducted using the terms “clinical inertia” and “type 2 diabetes.” Finally, we used the reference lists from papers that were identified in these searches to find additional literature that was relevant to our questions.


Our searches yielded a multitude of studies examining various aspects of treatment intensification using administrative databases.3-6,19-21 These and similar reports, which use sources such as patient medical records, insurance claims, and pharmacy data, leave little doubt that diabetes treatment recommendations are often not followed in practice. The absence of qualitative factors that place objective clinical data in a real-life context was an almost universal and far-reaching limitation of these reports, and the lack of this type of information might explain appropriate decision making that results in lack of treatment intensification for some portion of those instances when intensification is called for by guidelines.

Providers’ Perceptions of Their Patients

A number of reports that collected information on providers’ perceptions of key patient characteristics suggested that these perceptions­ strongly influenced treatment decisions, making it important to assess and address (as appropriate), these perceptions and any other barriers to intensification as delivery systems focus on improving chronic care. For example, one study surveyed 83 primary care physicians in 3 states and provided unusually detailed information concerning qualitative factors that underpin their diabetes treatment decisions.22 Results indicated that although 69% of respondents agreed with guidelines stipulating A1C targets of <7%, more than half also reported that they would raise the target value depending on factors such as life expectancy, poor patient self-management, low educational attainment or health literacy. When asked why they would decide not to initiate insulin, 43% expressed concerns about self-management skills. Nearly half of these providers indicated that they would determine that a patient was incapable of managing insulin therapy based on their perception of the patient’s self-management skills.

Further, 77% reported that they would not initiate insulin “some” or “most” of the time if they felt the patient’s adherence to oral medication was low, and an additional 5% said they would never initiate insulin under these circumstances. Similar findings were noted in a survey of 886 members of the Society of General Internal Medicine and the American Diabetes Association that confirmed that among both generalists and specialists, physician perceptions of certain patient characteristics influence the choice of initial hypoglycemic therapy as well as the choice to initiate insulin.23 For example, 59% of specialists and 57% of generalists reported that patients’ adherence behavior influenced the choice of initial therapy, and 67% and 71% of the 2 groups reported that patients’ motivation to improve influences their choice to initiate insulin. A similar study reported that providers tended to prescribe insulin more frequently when they believed patients were more adherent to medication regimens.24

Against this backdrop, it is instructive to consider the impact of patient age on physician perceptions that may influence treatment decisions. One notable study surveyed more than 500 primary care physicians and asked them to provide information on their patients with diabetes aged 65 years or more who were newly diagnosed and who had not started treatment during the past 6 months.25 Almost half of the physicians who responded to this survey reported that they had concerns about hypoglycemic treatment in the elderly. Indeed, although a large portion of the 770 patients in this study had A1C <7%, fully one-third had A1C exceeding 7%. When asked why these older patients were not started on therapy, physicians frequently reported that they were still trying to manage the patient with diet and exercise, that the patient’s hyperglycemia was “mild,” or that they had concerns about antihyperglycemic agents in older patients, as well as concerns about patient comorbidities and polypharmacy in this patient population.

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