Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
State Health Department of Negeri Sembilan, Seremban, Malaysia.
PLoS One. 2020 Oct 9;15(10):e0240531. doi: 10.1371/journal.pone.0240531. eCollection 2020.
Clinical inertia can lead to poor glycemic control among type 2 diabetes patients. However, there is paucity of information on clinical inertia in low- and middle-income countries including Malaysia. This study aimed to determine the time to treatment intensification among T2D patients with HbA1c of ≥7% (≥53 mmol/mol) in Malaysian public health clinics. The proportion of patients with treatment intensification and its associated factors were also determined.
This was a five-year retrospective open cohort study using secondary data from the National Diabetes Registry. The study setting was all public health clinics (n = 47) in the state of Negeri Sembilan, Malaysia. Time to treatment intensification was defined as the number of years from the index year until the addition of another oral antidiabetic drug or initiation of insulin. Life table survival analysis based on best-worst case scenarios was used to determine the time to treatment intensification. Discrete-time proportional hazards model was fitted for the factors associated with treatment intensification.
The mean follow-up duration was 2.6 (SD 1.1) years. Of 7,646 patients, the median time to treatment intensification was 1.29 years (15.5 months), 1.58 years (19.0 months) and 2.32 years (27.8 months) under the best-, average- and worst-case scenarios respectively. The proportion of patients with treatment intensification was 45.4% (95% CI: 44.2-46.5), of which 34.6% occurred only after one year. Younger adults, overweight, obesity, use of antiplatelet medications and poorer HbA1c were positively associated with treatment intensification. Patients treated with more oral antidiabetics were less likely to have treatment intensification.
Clinical inertia is present in the management of T2D patients in Malaysian public health clinics. We recommend further studies in lower- and middle-income countries to explore its causes so that targeted strategies can be developed to address this issue.
临床惰性可导致 2 型糖尿病患者血糖控制不佳。然而，包括马来西亚在内的中低收入国家关于临床惰性的信息很少。本研究旨在确定马来西亚公共卫生诊所中糖化血红蛋白（HbA1c）≥7%（≥53mmol/mol）的 2 型糖尿病患者的治疗强化时间。还确定了患者进行治疗强化的比例及其相关因素。
这是一项使用马来西亚国家糖尿病登记处的二级数据进行的为期五年的回顾性开放队列研究。研究地点是马来西亚 Negeri Sembilan 州的所有公共卫生诊所（n=47）。治疗强化时间定义为从索引年度到添加另一种口服抗糖尿病药物或开始使用胰岛素的年份数。基于最佳最差情况的寿命表生存分析用于确定治疗强化时间。离散时间比例风险模型用于拟合与治疗强化相关的因素。
平均随访时间为 2.6（SD 1.1）年。在 7646 名患者中，最佳、平均和最差情况下治疗强化的中位数时间分别为 1.29 年（15.5 个月）、1.58 年（19.0 个月）和 2.32 年（27.8 个月）。进行治疗强化的患者比例为 45.4%（95%CI：44.2-46.5），其中 34.6%仅在一年后发生。年轻成年人、超重、肥胖、使用抗血小板药物和较差的糖化血红蛋白与治疗强化呈正相关。使用更多口服抗糖尿病药物的患者不太可能进行治疗强化。
马来西亚公共卫生诊所 2 型糖尿病患者的治疗管理中存在临床惰性。我们建议在中低收入国家进一步研究，以探索其原因，以便制定有针对性的策略来解决这一问题。
