Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3046 — No Association between Mental Health Disorders and Clinical Inertia in Veterans with Diabetes

Jones LE (HSR&D Center for Implementing Evidence-Based Practices (CIEBP), Roudebush VAMC, Indianapolis) , Chou AF (University of Oklahoma), Halanych J (Deep South Center on Effectiveness at the Birmingham VA Medical Center; University of Alabama at Birmingham), Houston T (Deep South Center on Effectiveness at the Birmingham VA Medical Center; University of Alabama at Birmingham), Levine D (Deep South Center on Effectiveness at the Birmingham VA Medical Center; University of Alabama at Birmingham), Slovensky D (University of Alabama at Birmingham), Allison J (University of Alabama at Birmingham), Safford M (Deep South Center on Effectiveness at the Birmingham VA Medical Center; University of Alabama at Birmingham)

Objectives:
Clinical inertia, a phenomenon where health care providers fail to initiate or intensify medical therapy when indicated, is recognized as the most important obstacle for achieving optimal control of chronic disease. Clinical inertia may differentially affect patients with mental health disorders (MHD) for reasons including complexity of disease management, competing demands, stigma, time and resource constraints, and/or fragmented care. The objective of this study was to determine if MHD type and severity were associated with clinical inertia in veterans with diabetes.

Methods:
Linked clinical, administrative, and pharmacy data (1997-2005) from a Midwestern VA facility were analyzed. Diabetic subjects were included if: (1) the most recent HbA1c value was >8%; (2) insulin had not been prescribed prior to the HbA1c test date; and (3) the subject had received diabetes medication(s) in the 90-days prior to HbA1c testing. A patient had “any MHD” if ICD-9 codes for a DSM-IV disorder were present prior to HbA1c testing. A patient was classified into a single DSM-IV category based on the clinically predominant MHD. The severity of the MHD was based on presence of a psychiatric hospitalization. A dichotomous outcome variable—medication intensification—was assessed in the 30-day period following the most recent HbA1c test. Medication intensification occurred if the dosage increased and/or a new diabetes medication was prescribed. Multivariate logistic regression, adjusted for salient demographic, clinical, and healthcare utilization characteristics, was conducted to determine the association between MHD and medication intensification.

Results:
1,662 subjects met study inclusion criteria; 55% (n=916) had a MHD. Subjects with MHD were more likely to be younger, Caucasian, have service-connected disability, unmarried, and have more medical comorbidity. Medication was intensified in 69% and 73% of patients with and without MHD, respectively. In multivariate analyses, no differences were observed between those with and without MHD (OR=0.89; 95% CI: 0.71-1.13) and MHD severity was not associated (OR=0.90; 95% CI: 0.61-1.34) with clinical inertia. However, subjects with substance disorders were 71% less likely (95% CI: 0.52-0.96) to receive drug intensification than subjects without MHD.

Implications:
MHD type and severity were not associated with clinical inertia in veterans with diabetes, with the exception of substance disorders.

Impacts:
Disparities in diabetic outcomes among patients with and without MHD may become less problematic given that clinical inertia does not differentially affect patients with MHD. However, additional research is required to determine why patients with substance disorders have an increased risk of clinical inertia.