Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners

Abstract

Background Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines. Methods Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence. Results Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified. Conclusions The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.

The Reasons for the Low Uptake of New Antidiabetic Drugs with Cardiovascular Effects—A Family Doctor Perspective

“…This may be particularly challenging in circumstances such as starting insulin therapy, introducing new medications in the treatment plan or attempting to achieve glycemic control by combining two or more oral antidiabetic drugs, as is usual in older patients with multiple comorbidities [ 40 ]. In such cases, family physicians tend to pass the responsibility of choosing the treatment to endocrinologists, trying to avoid any anxiety that may arise due to the side effects of intensifying the therapy or using medications that they have less experience with [ 41 ].…”

“…It is assumed that education on psychological factors that influence patient behavior in care uptake would reduce the providers’ uncertainties during decision-making and should become a part of implementation strategies [ 42 ]. In addition, family physicians may have strong attitudes towards certain medications that they have experience with and that are well accepted by patients and may be hesitant to try new treatments, despite the evidence of their efficacy [ 41 ]. Based on that, it is important to research the psychological factors that may influence family doctors’ attitudes towards their behavioral intentions and decisions for action, as well as doctor–patient communication, which can shape behavioral changes.…”

“…Overall, clinical guidelines are generally not designed to suit the working style of primary care providers and family physicians [ 39 , 44 ]. In addition, there is a lack of competency-based workflow and effective communication models between different disciplines, which can also contribute to the non-adherence of family physicians to the guidelines [ 41 ]. The research performed thus far has identified several categories of barriers and enablers regarding the implementation of clinical guidelines in primary care [ 8 , 45 , 46 ].…”

Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands

“…The main reason not to use laxatives in the recent Dutch study was that patients did not consider them necessary [ 16 ], but the underlying motivation for these perceptions remains unclear as well as the perceptions of prescribers. Non-adherence to guidelines by physicians may be caused by factors such as lack of agreement with guideline recommendations [ 21 , 22 ], lack of outcome expectancy or self-efficacy [ 23 ], external limitations (e.g. time, tools) [ 23 ] and/or recommendations not applicable to specific patients [ 21 , 22 ].…”

“…Non-adherence to guidelines by physicians may be caused by factors such as lack of agreement with guideline recommendations [ 21 , 22 ], lack of outcome expectancy or self-efficacy [ 23 ], external limitations (e.g. time, tools) [ 23 ] and/or recommendations not applicable to specific patients [ 21 , 22 ]. Whether these reasons also apply to non-adherence to guidelines on laxative prescribing in opioid users is unclear.…”