Improving cardiovascular risk factor control is the key to primary cardiovascular disease prevention. The proportion of patients who met HbA1c, BP, and LDL-C goals in this study was extremely low (5.86%), and 27.65% did not meet any of the three goals. The prevention of cardiovascular disease is highly challenging.
In a study published in 2013[20], the proportion of outpatients in China with T2DM who met their HbA1c target was 48%. According to data gathered by Li Sha et al. in Beijing from 2011 to 2015 on 1260 patients with stable coronary artery disease and diabetes, 44.2% of participants met the HbA1c threshold advised by the guidelines[21]. Data from 173 642 participants in a cross-sectional, nationally representative survey conducted in China in 2018 revealed that 50.1% of patients undergoing therapy had acceptable glycemic control[22]. The rate of glycaemic control in our study was 38.54%, which was lower than that in other studies carried out in China. This difference may be due to the fact that patients with ACS who had lower glycaemic control rates were included in our study. Other countries are also experiencing a situation in which diabetes control has not significantly improved. A cross-sectional analysis of data from adults with diabetes in the United States revealed that the rate of glycaemic control (glycated haemoglobin level, < 7%) fell from 57.4% in 2007–2010 to 50.5% in 2015–2018[23]. Glycemic control was observed in 42% of participants in Mexico in 2018 and 39% in 2020[24]. With the advancement of clinical research and the continuous emergence of new treatment methods, there are more and more options for the treatment of diabetes, but overall blood glucose control in diabetic patients remains a major challenge. Researchers all over the world have been concerned about the issue of therapeutic inertia. Overcoming therapeutic inertia has gradually become a significant breakthrough in diabetes control [25].
Most countries experience therapeutic inertia. The overall therapeutic inertia rate of DM2 in this study was 55.96%. This figure was comparable to what was reported in other countries. 449 family physicians collected data on 10275 T2DM patients in a national study conducted in a primary care setting in Croatia, and the mean therapeutic inertia per family physician was 55.6%[26]. Diabetes treatment was only intensified in 50% of clinical patients, according to a study of urban African Americans[27]. It is estimated that 38.5% of diabetic patients in Taiwan suffer from therapeutic inertia[28]. In 2013, the medication status of 2783 diabetic patients in primary care centers in Spain was examined, with 997 (35.8%) having HbA1c > 7%. Only 66.8% of patients received intensive treatment, implying that therapeutic inertia existed in 33.2% of patients[29]. Another study published in 2021 in Spain found therapeutic inertia in 42.9% of 1628 people with HbA1c ≥ 7.5% [58 mmol/mol] [30]. In a systematic review by Kamlesh Khunti et al., the median time to treatment intensification after a glycated haemoglobin (HbA1c) measurement above target was more than 1 year[31].
Our findings also show that cardiologists' enthusiasm for blood glucose treatment intervention is significantly related to blood glucose levels. For patients with HbA1c ≥ 9.0%, therapeutic inertia only exists in 28% of patients, and cardiologists also actively seek the assistance of endocrine specialists. With the decrease of HbA1c level, therapeutic inertia seems to be gradually increasing. This can be as a result of clinicians' awareness of blood glucose management objectives. Although less stringent A1C goals (such as < 8%) may be appropriate for patients with a short life expectancy or in cases where the risks of treatment outweigh the benefits, we used strict control criteria for blood glucose control in this study.
The causes of therapeutic inertia are multifaceted and complex. Aside from the patient's factors, the medical system and doctors are responsible for a large portion of the reasons. According to a Taiwanese study, 88.92% of the variation in the use of intensified treatment occurred within physicians[28], and the odds ratio for cardiologists choosing to intensify therapy was 0.708 times that of endocrinologists. Based on the review of medical records, we discovered that the cardiologist advised some diabetic patients to see an endocrinologist at the clinic after discharge. This could be because the average length of hospitalization for patients with CAD was 5.48 days, leaving cardiologists with insufficient time to intensify treatment regimens. However, it is possible that cardiologists lack the necessary expertise to treat diabetes. The survey reveals that a lack of formal postgraduate diabetes training, differences in the recommendations of guidelines, fear of hypoglycemia, etc. are the primary barriers to healthcare professionals' immobility[32, 33].
Therapeutic inertia can occur at any stage of diabetes treatment, including diet and exercise control, oral drug administration, and insulin injections. Clinicians, nurses, patients, the medical system, and the social environment all play critical roles in the treatment of diabetes at various stages of the disease. To effectively address the problem of therapeutic inertia in T2DM, systematic intervention from doctors, patients, and the health system is required. Facts show that pharmacists, nurses, and other members of the interdisciplinary team who participate in disease education and management are effective[34–36].