GPs' approach to insulin prescribing in older patients: a qualitative study

Abstract

Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AimTo explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. Design of studyQualitative individual interviews using a grounded theory approach. SettingPrimary care. MethodA thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. ResultsTwenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. ConclusionGPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed. Keywordsinsulin; primary health care; qualitative research; type 2 diabetes mellitus.

Diabetes management in an Australian primary care population

“…A low proportion of patients were on insulin therapy, notwithstanding their poor glycaemic control. This may reflect the ongoing reluctance of GPs to initiate insulin therapy early and aggressively enough to reach glycaemic targets (27) despite the strong evidence supporting its earlier introduction to prevent complications (23, 28). Major reasons for this are unfounded fears among patients over the possibility of increased macrovascular risk with insulin and concerns regarding the risk of hypoglycaemia and of exacerbating weight gain (29).…”

Physician Reasons for Nonpharmacologic Treatment of Hyperglycemia in Older Patients Newly Diagnosed with Type 2 Diabetes Mellitus

“…Although there have been studies of physicians’ attitudes toward recommending lifestyle changes after a diagnosis of T2DM [12, 13], or their attitudes toward treatment intensification with insulin [14–17], there are limited data evaluating the reasons given by primary care physicians for not initiating antihyperglycemic therapy in older patients with T2DM. Therefore, the objectives of the present study were, first, to describe the clinical characteristics of patients aged ≥65 years who had not been treated with oral antihyperglycemic therapy in the 6 or more months following diagnosis of T2DM, and second, to report the reasons given by primary care physicians for not initiating oral antihyperglycemic therapy in their patients.…”

Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

“…Relative inexperience and lack of confidence prescribing insulin; nurses better at guideline adherence. 30,33,39,43 Concern that those with impairments or older people could find complicated regimens difficult. 33,42 -…”

“…The everincreasing demand to reach tighter and tighter guidelines, and the limited resources available to help us do that …' (Physician) 33 Given the increased number of patients managed in primary care, specialists can play an important guiding role, although communication is not always optimal:…”

“…33,57 Symptom improvement and emphasising the value of treatment to reinforce practice. 33,44 Incentive payments for insulin initiation. 59 Blood pressure…”