Therapeutic inertia in type 2 diabetes mellitus: perception of general practitioners from Almada-Seixal health care centers
DOI:
https://doi.org/10.32385/rpmgf.v38i1.13061Keywords:
Therapeutic inertia, Diabetes mellitus type 2, InsulinAbstract
Introduction: Our study aimed at identifying barriers to the initiation of insulin therapy and its associated sociodemographic and labor factors.
Material and Methods: This cross-sectional study was carried out through a survey applied to 146 general practitioners working in Almada and Seixal primary health care centers, between October and December 2019, assessing their agreement on 30 barriers using a 5-point Likert scale. We used logistic regression to measure the association between each item’s agreement and physician’s factors.
Results: The response rate was 74%. Physicians’ average age was 44 years, 75% were women and 64% worked in model B family health units. Most physicians agreed with the barriers related to patients’ characteristics and insulin’s positive impact on the prognosis of patients. They disagreed with the ones associated with the possibility of harming the doctor-patient relationship and having doubts about who is responsible and when to start insulin. Older doctors disagreed with barriers related to patients’ characteristics and lack of training. As the professional category increases, physicians tend to disagree with factors related to the lack of training, experience, and the doctor-patient relationship. Physicians from non-reformed health units agree that they do not have a multidisciplinary team appropriate for diabetes care.
Discussion: We identified barriers already described in the literature, especially for younger doctors, in residency and from non-reformed health units.
Conclusion: These results may be used locally to improve the training of younger doctors and to create multidisciplinary teams dedicated to diabetes in non-reformed health units.
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References
Raposo JF. Diabetes: factos e números 2016, 2017 e 2018. Rev Port Diabetes. 2020;15(1):19-27.
Cosme M, San-Bento A, Alves R, Martins JV, Cerdas S, Fernandes V, et al. Plano Local de Saúde Almada-Seixal 2017-2020 [Internet]. Almada: ACeS Almada-Seixal; 2017. Available from: http://1nj5ms2lli5hdggbe3mm7ms5.wpengine.netdna-cdn.com/files/2017/09/PLS_Almada_Seixal.pdf
American Diabetes Association. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes – 2019. Diabetes Care. 2019;42(Suppl 1):S13-28.
Direção-Geral da Saúde. Insulinoterapia na diabetes mellitus tipo 2: norma n.º 021/2011, de 29/09/2011, atualizada em 17 de janeiro de 2014. Lisboa: DGS; 2014.
Lang VB, Marković BB, Kranjčević K. Family physician clinical inertia in glycemic control among patients with type 2 diabetes. Med Sci Monit. 2015;21:403-11.
Shah BR, Hux JE, Laupacis A, Zinman B, Van Walraven C. Clinical inertia in response to inadequate glycemic control: do specialists differ from primary care physicians? Diabetes Care. 2005;28(3):600-6.
Triplitt C. Improving treatment success rates for type 2 diabetes: recommendations for a changing environment. Am J Manag Care. 2010;16(7 Suppl):S195-200.
Lourenço C, Reis M, Vitorino P. Relatório preliminar de avaliação da contratualização em cuidados de saúde primários: ano 2015 [Internet]. Lisboa: Administração Regional de Saúde de Lisboa e Vale do Tejo; 2016. Available from: https://www.arslvt.min-saude.pt/uploads/document/file/2907/RELAT_RIO_DE_AVALIA__O_DA_CONTRATUALIZA__O_EM_CSP_ANO_2015_vers_o_sint_tica.pdf
Martins A, Reis M. Relatório de avaliação da contratualização em cuidados de saúde primários: Unidades de Saúde Familiar (USF) e Unidades de Cuidados de Saúde Personalizados (UCSP) – ano 2013 e 2014 [Internet]. Lisboa: Administração Regional de Saúde de Lisboa e Vale do Tejo; 2016. Available from: https://www.arslvt.min-saude.pt/uploads/document/file/2501/RELAT_RIO_2014_2013_USF_E_UCSP.pdf
Bilhete de identidade dos indicadores dos cuidados de saúde primários para o ano de 2017 [Internet]. Lisboa: Serviço Nacional de Saúde; 2017 [cited 2019 Mar 3]. Available from: https://www.sns.gov.pt/wp-content/uploads/2017/04/bilhete_identidade_indicadores_contratualizacao_2017.pdf
Osataphan S, Chalermchai T, Ngaosuwan K. Clinical inertia causing new or progression of diabetic retinopathy in type 2 diabetes: a retrospective cohort study. J Diabetes. 2017;9(3):267-74.
Mahabaleshwarkar R, Gohs F, Mulder H, Wilkins N, DeSantis A, Anderson WE, et al. Patient and provider factors affecting clinical inertia in patients with type 2 diabetes on metformin monotherapy. Clin Ther. 2017;39(8):1658-70.
Khunti K, Millar-Jones D. Clinical inertia to insulin initiation and intensification in the UK: a focused literature review. Prim Care Diabetes. 2017;11(1):3-12.
Ng CJ, Lai PS, Lee YK, Azmi SA, Teo CH. Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review. Int J Clin Pract. 2015;69(10):1050-70.
Ross SA. Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes. Am J Med. 2013;126(9 Suppl 1):S38-48.
Lakkis NA, Maalouf GJ, Mahmassani DM, Hamadeh GN. Insulin therapy attitudes and beliefs of physicians in Middle Eastern Arab countries. Fam Pract. 2013;30(5):560-7.
Carratalá-Munuera MC, Gil-Guillen VF, Orozco-Beltran D, Navarro-Pérez J, Caballero-Martínez F, Alvarez-Guisasola F, et al. Barriers associated with poor control in Spanish diabetic patients: a consensus study. Int J Clin Pract. 2013;67(9):888-94.
Zafar A, Stone MA, Davies MJ, Khunti K. Acknowledging and allocating responsibility for clinical inertia in the management of Type 2 diabetes in primary care: a qualitative study. Diabet Med. 2015;32(3):407-13.
Mata-Cases M, Benito-Badorrey B, Roura-Olmeda P, Franch-Nadal J, Pepió-Vilaubí JM, Saez M, et al. Clinical inertia in the treatment of hyperglycemia in type 2 diabetes patients in primary care. Curr Med Res Opin. 2013;29(11):1495-502.
Berlowitz DR, Ash AS, Glickman M, Friedman RH, Pogach LM, Nelson AL, et al. Developing a quality of measure for clinical inertia in diabetes care. Health Serv Res. 2005;40(6 Pt 1):1836-53.
Bailey CJ. Under‐treatment of type 2 diabetes: causes and outcomes of clinical inertia. Int J Clin Pract. 2016;70(12):988-95.
Bain SC, Feher M, Russell-Jones D, Khunti K. Management of type 2 diabetes: the current situation and key opportunities to improve care in the UK. Diabetes Obes Metab. 2016;18(12):1157-66.
Strain WD, Cos X, Hirst M, Vencio S, Mohan V, Vokó Z, et al. Time to do more: addressing clinical inertia in the management of type 2 diabetes mellitus. Diabetes Res Clin Pract. 2014;105(3):302-12.
Hayes RP, Fitzgerald JT, Jacober SJ. Primary care physician beliefs about insulin initiation in patients with type 2 diabetes. Int J Clin Pract. 2008;62(6):860-8.
Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care. 2005;28(11):2673-9.
Hayat AS, Shaikh N. Barriers and myths to initiate insulin therapy for type 2 diabetes mellitus at primary health care centers of Hyderabad District. World Appl Sci J. 2010;8(1):66-72.
Furler J, Spitzer O, Young D, Best J. Insulin in general practice: barriers and enablers for timely initiation. Aust Fam Physician. 2011;40(8):617-21.
Haque M, Emerson SH, Dennison CR, Navsa M, Levitt NS. Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town. S Afr Med J. 2005;95(10):798-802.
Manski-Nankervis JA, Furler J, Blackberry I, Young D, O’Neal D, Patterson E. Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory. BMC Fam Pract. 2014;15:20.
Lee YK, Lee PY, Ng CJ. A qualitative study on healthcare professionals perceived barriers to insulin initiation in a multi-ethnic population. BMC Fam Pract. 2012;13:28.
Grant RW, Wexler DJ, Watson AJ, Lester WT, Cagliero E, Campbell EG, et al. How doctors choose medications to treat type 2 diabetes: a national survey of specialists and academic generalists. Diabetes Care. 2007;30(6):1448-53.
Burden ML, Burden AC. Attitudes to starting insulin in primary care. Pract Diabetes Int. 2007;24(7):346-50.
Lenz R, Ramírez J, Gac R, Lorca E. Dificultades en la prescripción racional de insulina: La percepción de los médicos tratantes de enfermos diabético de atención primaria de salud [Perceived difficulties among primary care physicians for the prescription of insulin for diabetic patients]. Rev Med Chile. 2010;138(3):281-8. Portuguese
Laerd Statistics. Ordinal regression using SPSS statistics [homepage]. Lund Research; 2018 [cited 2019 Mar 3]. Available from: https://statistics.laerd.com/spss-tutorials/ordinal-regression-using-spss-statistics.php
Ratanawongsa N, Roter D, Beach MC, Laird SL, Larson SM, Carson KA, et al. Physician burnout and patient-physician communication during primary care encounters. J Gen Intern Med. 2008;23(10):1581-8.
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