In their recent trial, O’Connor et al. (1) examined the effectiveness of a low-intensity telephone outreach intervention among adults with diabetes being prescribed new classes of medications for out-of-target glycemia, blood pressure, and lipids in a primary care setting. They attributed their negative trial outcomes to the brevity of the intervention, a single telephone call of up to 5 min duration by a trained health professional not based in the primary care setting. Furthermore, less than half (563/1,220) of intervention patients actually received a successful telephone contact. About three in four patients participating in the study filled their prescription either for uncontrolled glycemia, blood pressure, or LDL cholesterol within 60 days of the new prescription (primary adherence). However, the authors also observed a lack of intensification to add new classes of medications in subsequent clinical encounters. The authors concluded that more intensive and targeted approaches may be warranted.
In our study of outreach telephone coaching by practice nurses in Australian primary care settings (the Patient Engagement and Coaching for Health [PEACH] study), we found that a more intensive outreach intervention (median of three telephone contacts by the practice nurse per intervention patient, median of 30 min per call, reaching 75% of participants) also did not produce favorable outcomes (2). In our sample, 94% were on hypoglycemic agents, 72% on antihypertensive agents, and 64% on hypolipidemic agents at baseline (2,3). We did observe intensification of treatment during the 18-month follow-up period; for example, the proportion of intervention and control patients on insulin increased from 23% to 40% and from 24% to 35%, respectively.
We believe that addressing clinical inertia in primary care settings (4) requires a wider organizational health system approach. Management of diabetes in primary care settings is complex. Having a trained and dedicated health professional with sufficient time to engage and build rapport with patients, sustained over time, may be critical to supporting patient medication adherence and treatment intensification, but on its own, as evident in both studies, it is unlikely to be sufficient. Changing prescriber behavior is also an important component of a system-based approach to intensifying diabetes care at a population level.
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Duality of Interest. No potential conflicts of interest relevant to this article were reported.
