Overcoming Therapeutic Inertia in Newly Diagnosed Type 2 Diabetes—Results of a Randomized Trial

Introduction and Objective: Therapeutic inertia (TI) in type 2 diabetes (T2D) is well documented and leads to worse glycemic control. Timely metformin initiation increases the likelihood of achieving glycemic targets early after diagnosis. Unfortunately, metformin initiation after diagnosis remains suboptimal. We conducted a cluster-randomized trial of PCP education with and without proactive pharmacist outreach to address TI among adults recently diagnosed with T2D who were not prescribed or were non-adherent to metformin. Methods: We randomized service areas within an integrated care system to 3 arms: 1) Usual care, 2) PCP education on TI, and 3) PCP TI education plus a pharmacist call to discuss metformin and self-management. Eligible people were patients of PCPs in randomized areas, ages 18-64, who had a recent T2D diagnosis with a most recent A1c of 6.5-7.9% who were not prescribed or were non-adherent to metformin (adults with A1c≥8% receive pharmacist outreach as standard-of-care). Primary outcomes included A1c<7% and A1c<8% at 6 and 12 months, and secondary outcomes included metformin initiation. T-tests, chi-square tests, and random-effects logistic regression were used to test for between-arm differences. Results: A total of 877 individuals were randomized (Arm 1: 257, Arm 2: 255, Arm 3: 305), with a mean A1c of 6.9%. Patients in the intervention arms had significantly better A1c levels at 6 months (A1c<7%: 81% Arm 3, 76% Arm 2) than usual care (70% Arm 1, p=0.03). This benefit was sustained at 12 months (A1c<8%: 97% Arm 3, 96% Arm 2, 87% Arm 1, p <0.01). Arm 3 patients had higher odds of starting metformin at 6 months (OR 1.53 CI:1.02, 2.29, ref=Arm 1, OR 1.75 CI: 1.16, 2.64, ref=Arm 2) though pharmacists only reached 60% of Arm 3 patients. Conclusion: In this trial, combining PCP education and pharmacist outreach resulted in less glycemic deterioration and increased odds of metformin initiation. These findings highlight the potential of a low-touch, proactive intervention leveraging non-physician clinicians to improve T2D outcomes. Disclosure: C. Board: None. J. Johnston: None. T.K. Thai: None. E. Huynh: None. A. Chan: None. J. Nugent: None. L.K. Gilliam: None. R.W. Grant: None. A. Gopalan: None.