Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands

Abstract

Aim

Because Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients.

Methods

Questionnaire to half of the Dutch general practitioners (GPs) (n = 3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages.

Results

Total response was 42% (n = 1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives.

Conclusion

This nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.

Introduction

In order to manage the increasing numbers of diabetes patients, general practitioners (GPs) have been encouraged to extend their involvement in diabetes care [1], [2], [3]. After treatment failure of lifestyle interventions plus oral medication, type 2 diabetes patients will require insulin treatment in order to achieve adequate glycaemic control [4]. Traditionally the conversion to insulin therapy has been managed in the secondary care setting, but nowadays more and more GPs in the Netherlands initiate insulin therapy themselves instead of referring patients to the hospital. An earlier publication of this questionnaire study demonstrated that in 2005 43% of the Dutch participating GPs employed a practice nurse, 13% a diabetes nurse and 12% both [5]. 67% of the GPs worked in practices where diabetes clinics were organised, mainly run by practice nurses. The study also showed that the more structured practices more often initiate insulin therapy themselves. More than 90% of the GPs and practice nurses have had professional education on any subject concerning diabetes during the last 3 years. In the most recent guidelines on type 2 diabetes from the Dutch College of General Practitioners, GPs are recommended to start insulin therapy themselves in a regimen of once daily insulin in combination with oral medication, when indicated. Furthermore, the guidelines provide detailed therapy schemes for both once daily, twice daily and basal-bolus insulin regimens, with indications for switching from one therapy schedule to another as well [1]. Nevertheless, many GPs and patients hesitate to accept the necessity of the conversion from oral medication to insulin therapy [6]. Patient factors that contribute to this reluctance have been examined in several studies. Reported factors were fear of hypoglycaemia and weight gain, ‘needle anxiety’, reluctance to restrictions in lifestyle and feelings of guilt and failure [6], [7], [8], [9], [10], [11]. Contributing barriers of the health care professional in starting insulin have less extensively been described and include concerns regarding hypoglycaemia and weight gain related to insulin therapy [8], [11], [12]. A recent study suggested that a general reluctance to prescribe diabetes medication serves as a barrier to prescription of insulin as well [9]. Because Dutch health care organisations want to establish well-defined diabetes shared care groups all over the country, it is relevant to know how many Dutch GPs start or monitor insulin therapy and to investigate what the determinants are for providing insulin therapy in primary care.

The current study aimed to investigate the organisation of insulin therapy in general practice in the Netherlands and to assess factors that are associated with providing insulin therapy.