James Best D Best
Insulin is effective at lowering blood glucose, and most people with type 2 diabetes need insulin within 10 years of diagnosis. However, initiating insulin is often delayed in general practice. This study explores barriers and enablers to insulin initiation in general practice.
A qualitative study using semistructured, in-depth interviews. Ten general practitioners, four diabetes nurse educators and 12 patients were interviewed. Participants were purposively selected and recruited through snowballing. Data analysis drew on the Normalisation Process Model framework.
The understanding of the primary aim of diabetes care and its context (improving pathophysiology, complex multimorbidity, the patient-doctor relationship, impact of living with the condition) was important. There was disagreement and uncertainty about whose role it is to initiate insulin. It was also important whether insulin initiation was conceptualised as a simple, protocol driven intervention, or as a complex and demanding addition to an overwhelming clinical picture.
Insulin initiation seems more likely if the multiple perspectives on the primary aim of clinical care are acknowledged, and if roles are explicitly discussed and clarified.
Most patients with type 2 diabetes require insulin therapy within 10 years of diagnosis to maintain normoglycaemia.1 Insulin is effective in improving glycaemic control, and simple patient driven algorithms using long acting insulin analogues are safe, effective2-5 and acceptable to patients.6 Yet, progression to insulin is often delayed, causing unnecessary prolonged periods of hyperglycaemia and preventable complications downstream.7
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