In the JournalsPerspective

PCPs lack sufficient knowledge on insulin use

A primary care physician’s lack of education on insulin use was one of the barriers to optimal use of insulin among patients with type 2 diabetes, according to data recently published in BMC Family Practice.

“While previous reviews have explored some of the factors related to why insulin use often fails to deliver good outcomes, these factors have not been considered systematically in the context of the management of [type 2 diabetes] in primary care from both the patient and health care professional perspectives collectively,” Kathy Ellis, a research student at King’s College London, and colleagues wrote.

Researchers conducted a thematic synthesis of studies that discussed the experiences and views of 65 primary care physicians, eight practice nurses, three diabetes nurse educators, two endocrinologists and one pharmacist who manage patients with type 2 diabetes. Similar information from 173 adults aged 23 to 90 years with type 2 diabetes was also analyzed.

Barriers among health care professionals

Ellis and colleagues found that the most frequently cited barriers among the health care professionals were lack of education on the technical aspects of insulin and psychosocial factors that influence insulin use; time available for appointments; and the relationship between care and continuity of support

“Given the findings of the patient accounts, this education needs to offer more than the technical aspects of insulin and should include an understanding of the psychosocial factors that may influence insulin use. In relation to time, it may be important to identify the role of other team members in delivering insulin support such as primary care nurses or diabetes specialist nurses supporting the primary care team,” Ellis and colleagues wrote.

Obstacles in health care systems

Researchers also examined obstacles in health care systems regarding insulin use and found these were mostly organizational.

“To ensure that insulin is used optimally in primary care ... the care system needs to be designed to ensure that patients are assessed and followed up by an appropriately trained [health care professional], who can provide continuity in their care experience. The system also needs to consider how to integrate specialist diabetes support to help the primary care teams in their clinical decision making and in building the resources that patients will need to support their insulin use,” they wrote.

Barriers among patients

Ellis and colleagues looked at barriers to insulin use among patients and found that these included experiences using and knowledge regarding the medication, psychosocial factors, self-management skills and underlying beliefs about insulin.

“The findings suggest that as well as the technical aspect of self-management, the support provided needs to consider the patients’ underlying beliefs, their psychological orientation to insulin and the influence of wider social factors. Addressing the problem of clinical and psychological inertia of the intensification of insulin therapy is key part of the process,” Ellis and colleagues wrote.

Researchers added that addressing the stigma surrounding insulin use, whether the patient wants to manage his or her own insulin use, and the family dynamics surrounding the patient’s use of the medication could also lead to greater uptake among patients. - by Janel Miller

 

Disclosure: The authors declare no relevant financial disclosures.

A primary care physician’s lack of education on insulin use was one of the barriers to optimal use of insulin among patients with type 2 diabetes, according to data recently published in BMC Family Practice.

“While previous reviews have explored some of the factors related to why insulin use often fails to deliver good outcomes, these factors have not been considered systematically in the context of the management of [type 2 diabetes] in primary care from both the patient and health care professional perspectives collectively,” Kathy Ellis, a research student at King’s College London, and colleagues wrote.

Researchers conducted a thematic synthesis of studies that discussed the experiences and views of 65 primary care physicians, eight practice nurses, three diabetes nurse educators, two endocrinologists and one pharmacist who manage patients with type 2 diabetes. Similar information from 173 adults aged 23 to 90 years with type 2 diabetes was also analyzed.

Barriers among health care professionals

Ellis and colleagues found that the most frequently cited barriers among the health care professionals were lack of education on the technical aspects of insulin and psychosocial factors that influence insulin use; time available for appointments; and the relationship between care and continuity of support

“Given the findings of the patient accounts, this education needs to offer more than the technical aspects of insulin and should include an understanding of the psychosocial factors that may influence insulin use. In relation to time, it may be important to identify the role of other team members in delivering insulin support such as primary care nurses or diabetes specialist nurses supporting the primary care team,” Ellis and colleagues wrote.

Obstacles in health care systems

Researchers also examined obstacles in health care systems regarding insulin use and found these were mostly organizational.

“To ensure that insulin is used optimally in primary care ... the care system needs to be designed to ensure that patients are assessed and followed up by an appropriately trained [health care professional], who can provide continuity in their care experience. The system also needs to consider how to integrate specialist diabetes support to help the primary care teams in their clinical decision making and in building the resources that patients will need to support their insulin use,” they wrote.

Barriers among patients

Ellis and colleagues looked at barriers to insulin use among patients and found that these included experiences using and knowledge regarding the medication, psychosocial factors, self-management skills and underlying beliefs about insulin.

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“The findings suggest that as well as the technical aspect of self-management, the support provided needs to consider the patients’ underlying beliefs, their psychological orientation to insulin and the influence of wider social factors. Addressing the problem of clinical and psychological inertia of the intensification of insulin therapy is key part of the process,” Ellis and colleagues wrote.

Researchers added that addressing the stigma surrounding insulin use, whether the patient wants to manage his or her own insulin use, and the family dynamics surrounding the patient’s use of the medication could also lead to greater uptake among patients. - by Janel Miller

 

Disclosure: The authors declare no relevant financial disclosures.

    Perspective
    Melanie Teslik

    Melanie Teslik

    It is important that there is continued research on all aspects of diabetes care, including insulin use. There have been dynamic changes in the treatment of diabetes in the last 5 years that is not reflected in the article. The American Diabetes Association’s Standards of Practice algorithm to achieve an HbA1c appropriate for the individual reflects the options now available. There is now the ease of use of insulin pens and 4 mm pen needles. There are many types of insulin that can address many of the concerns found in the article. Alternatives to daily finger sticks such as continuous glucose monitors are now available. Often the choices to treat diabetes relate to cost and reimbursement by the patient’s insurance and not what is best for the individual with diabetes.

    The article has pointed out key aspects that have been identified as challenges in the treatment of diabetes, such as perception, cultural beliefs and cost. One area not touched upon is the emergence of technology. Patients are now able to research diabetes online to address some of their questions and concerns and seek more specific answers during appointments.

    Sites such as the American Association of Diabetes Educators and the American Diabetes Association empower the individual with a wealth of information. The content found on these sites are supported by research. There is educational material for both the patient and the health care provider available.

    Patients can now communicate with their physician via phone, email or text. This allows support between visits, which often leads to better compliance by the patient. The primary physician now uses technology to communicate with other specialists to coordinate the care provided to the patient.

    It is unrealistic to believe the primary physician can address all aspects of a patient’s care without support. One conclusion that is extremely important is the use of specialized educators such as a certified diabetes educator. As a member of the health care team, they can assist with assessing a patient’s ability to achieve their goals and develop a plan to implement the decisions agreed upon by the patient and the team.

    The focus of health care is now patient-centered with shared decision-making to develop mutual goals. Collaboration is the key to better compliance with all aspects of diabetes, not just taking insulin injections. A complete assessment is needed to address literacy, personal beliefs, support system, risk reduction, psychosocial issues, behavioral changes and ability to perform tasks required to address diabetes (ie, injections, finger sticks, diet, exercise). The most important area to address is the patient’s readiness for change. There are many educational programs available to empower the individual, including diabetes self-management education and support (DSMES) for type 2 diabetes. There is a need to communicate that these types of programs are available for initial and ongoing education.

    The greatest impact for the individual with diabetes can be achieved through education and teamwork.

    • Melanie Teslik, RN, MSN, CDE, BC-ADM, CPHQ
    • diabetes nurse educator, department of endocrinology, diabetes, and metabolism Winthrop University Hospital, New York University, spokesperson, American Association of Diabetes Educators

    Disclosures: Teslik reports no relevant financial disclosures.