Barriers that practitioners face when initiating insulin therapy in general practice settings and how they can be overcome

Abstract

AIMTo explore primary care physicians’ perspectives on possible barriers to the use of insulin.METHODSThis systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight electronic databases were searched (between January 1, 1994 and August 31, 2014) for relevant studies. A search for grey literature and a review of the references in the retrieved studies were also conducted. Studies that focused on healthcare providers’ perspectives on possible barriers to insulin initiation with type 2 diabetic patients were included, as well as articles suggesting solutions for these barriers. Review articles and studies that only considered patients’ perspectives were excluded.RESULTSA total of 19 studies met the inclusion criteria and were therefore included in this study: 10 of these studies used qualitative methods, 8 used quantitative methods and 1 used mixed methods. Studies included a range of different health care settings. The findings are reported under four broad categories: The perceptions of primary care physicians about the barriers to initiate insulin therapy for type 2 diabetes patients, how primary care physicians assess patients prior to initiating insulin, professional roles and possible solutions to overcome these barriers. The barriers described were many and covered doctor, patient, system and technological aspects. Interventions that focused on doctor training and support, or IT-based decision support were few, and did not result in significant improvement.CONCLUSIONPrimary care physicians’ known delay in insulin initiation is multifactorial. Published reports of attempts to find solutions for these barriers were limited in number.

Initiation and Titration of Basal Insulin in Primary Care: Barriers and Practical Solutions

“…Self blame and feelings of failure associated with the need to initiate insulin are frequently cited by patients and may be underestimated by PCPs. 15,36,37 In the Diabetes Attitudes, Wishes, and Needs (DAWN) study, physicians and diabetes nurses failed to recognize that patients' feelings of self blame were associated with delay of insulin initiation, which, combined with a common physician belief that insulin therapy should be delayed as long as possible, suggests a possible causal link between physician and patient attitudes. 47 Patients may be receiving messages from physicians that initiation of insulin represents a failure to control diabetes or a "punishment" for failing on their oral therapies.…”

“…38 Unfortunately, physicians may often underestimate patients' concerns that their disease will worsen following insulin initiation. 36,52 Another misperception that patients may have, in particular those who drive for a living, is that they will no longer be able to drive when on insulin therapy due to hypoglycemia risk. Clinicians can assure these patients that they can apply for an exemption to a rule that prevents interstate commercial driving while using insulin.…”

“…However, patients' social concerns regarding basal insulin therapy are frequently overlooked. 36,52 Social concerns are often related to perceived social stigma, which can result in, for example, a reluctance to inject insulin in public or around family members. 37,65 The fear that using basal insulin will interfere with the patient's daily routine is likely to have a negative effect on several aspects of their social life.…”

“…12 However, studies suggest that fear of injection pain is one of the factors most overestimated by PCPs when assessing their patients' receptiveness to therapy. 36,48,52 In clinical use, only 37% of patients using injection pens report injection-related pain. 67 However, fear of injection, like other barriers, may be anticipatory; it is often transient and tends to minimize or disappear once patients have started using basal insulin.…”

“…38 The initiation of basal insulin should never be used as a threat to attempt to maintain a patient's adherence to an exercise or OAD regimen. 8,36 To facilitate patient education, group-based DSMES programs, the use of mobile technology, and the use of diabetes educators and specialists in difficult cases can reduce the time burden of individual patient education. 92 Individualized patient care extends to understanding a patient's specific barriers to basal insulin therapy and is the first step in overcoming them.…”