Resistance to Insulin Therapy Among Patients and Providers
Objective: To examine the correlates of patient and provider attitudes toward insulin therapy.
Research Design And Methods: Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses.
Results: Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50–55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications.
Conclusions: Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose–lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.
Type 2 diabetes is characterized by defects in both insulin secretion and insulin action. The defect in insulin secretion seems to be progressive; newly diagnosed patients in the U.K. Prospective Diabetes Study had 50% of normal insulin secretion, and they had <25% of normal insulin secretion 6 years after diagnosis. As a consequence, good glycemic control in type 2 diabetes often requires insulin supplementation therapy. Unfortunately, many patients with type 2 diabetes who could benefit from insulin therapy do not receive it or do not receive it in a timely manner. Part of this gap appears to be attributable to resistance to taking insulin among patients and resistance to prescribing insulin among health care providers. This resistance is based on a variety of factors, primarily beliefs and perceptions regarding diabetes and its treatment, the nature and consequences of insulin therapy, and how others would regard insulin therapy. Treatment guidelines that have advocated insulin therapy only if all other treatment strategies have failed also may have contributed.
Resistance to insulin therapy in patients has been examined in several studies, although none with large samples. An early study reported that more than three-quarters of patients with type 2 diabetes who were about to initiate insulin therapy considered it a "severe crisis" in their illness. Several studies have identified patient attitudes that contribute to resistance to or acceptance of insulin therapy. Attitudes found to contribute to resistance to insulin therapy include the beliefs that taking insulin 1) leads to poor outcomes including hypoglycemia, weight gain, and complications; 2) means the patient's diabetes is worse and the patient has failed; 3) means life will be more restricted and people will treat the patient differently; and 4) will not make diabetes easier to manage. Attitudes facilitating acceptance of insulin therapy include the beliefs that taking insulin 1) leads to good short-term outcomes (e.g., lower blood glucose levels, with benefits such as feeling better and fewer symptoms) as well as long-term benefits (e.g., prolonged life and lower risk of complications), 2) is often required because of natural disease progression, and 3) could be easier with some available delivery systems. Patients whose health care provider recommended insulin therapy had more positive attitudes toward insulin.
With few exceptions, little is known about the factors related to prescribing diabetes medications, and insulin specifically, though there is substantial research about the correlates of provider willingness to prescribe medications in general. Specialists tend to prescribe more than general practitioners. Some physicians have a higher propensity to prescribe because they prefer medication over other forms of treatment. Physician beliefs about specific medications (e.g., efficacy, side effects, cost) are also associated with prescribing. And provider beliefs about patient attitudes toward medication are associated with level of prescribing.
Finally, attitudes toward insulin therapy may differ by country, perhaps as a function of cultural and health care system factors. International comparisons suggest that there are systematic differences among countries that are worthy of study.
The current report describes patient and provider attitudes toward insulin therapy and their correlates based on data from a large multinational study. We examine the degree to which providers' tendency to delay insulin therapy is associated with general orientation toward prescribing blood glucose–lowering agents, specific beliefs about insulin therapy, and perceptions of patient attitudes toward insulin. We also examine the degree to which patient perceptions of insulin's benefits and self-blame for needing to initiate insulin therapy are associated with perceived diabetes severity (control and complications), diabetes-related emotional distress, adherence to self-care recommendations, and quality of the patient-provider relationship. We also consider differences among countries in patient and provider resistance to initiating insulin therapy.
Objective: To examine the correlates of patient and provider attitudes toward insulin therapy.
Research Design And Methods: Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses.
Results: Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50–55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications.
Conclusions: Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose–lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.
Type 2 diabetes is characterized by defects in both insulin secretion and insulin action. The defect in insulin secretion seems to be progressive; newly diagnosed patients in the U.K. Prospective Diabetes Study had 50% of normal insulin secretion, and they had <25% of normal insulin secretion 6 years after diagnosis. As a consequence, good glycemic control in type 2 diabetes often requires insulin supplementation therapy. Unfortunately, many patients with type 2 diabetes who could benefit from insulin therapy do not receive it or do not receive it in a timely manner. Part of this gap appears to be attributable to resistance to taking insulin among patients and resistance to prescribing insulin among health care providers. This resistance is based on a variety of factors, primarily beliefs and perceptions regarding diabetes and its treatment, the nature and consequences of insulin therapy, and how others would regard insulin therapy. Treatment guidelines that have advocated insulin therapy only if all other treatment strategies have failed also may have contributed.
Resistance to insulin therapy in patients has been examined in several studies, although none with large samples. An early study reported that more than three-quarters of patients with type 2 diabetes who were about to initiate insulin therapy considered it a "severe crisis" in their illness. Several studies have identified patient attitudes that contribute to resistance to or acceptance of insulin therapy. Attitudes found to contribute to resistance to insulin therapy include the beliefs that taking insulin 1) leads to poor outcomes including hypoglycemia, weight gain, and complications; 2) means the patient's diabetes is worse and the patient has failed; 3) means life will be more restricted and people will treat the patient differently; and 4) will not make diabetes easier to manage. Attitudes facilitating acceptance of insulin therapy include the beliefs that taking insulin 1) leads to good short-term outcomes (e.g., lower blood glucose levels, with benefits such as feeling better and fewer symptoms) as well as long-term benefits (e.g., prolonged life and lower risk of complications), 2) is often required because of natural disease progression, and 3) could be easier with some available delivery systems. Patients whose health care provider recommended insulin therapy had more positive attitudes toward insulin.
With few exceptions, little is known about the factors related to prescribing diabetes medications, and insulin specifically, though there is substantial research about the correlates of provider willingness to prescribe medications in general. Specialists tend to prescribe more than general practitioners. Some physicians have a higher propensity to prescribe because they prefer medication over other forms of treatment. Physician beliefs about specific medications (e.g., efficacy, side effects, cost) are also associated with prescribing. And provider beliefs about patient attitudes toward medication are associated with level of prescribing.
Finally, attitudes toward insulin therapy may differ by country, perhaps as a function of cultural and health care system factors. International comparisons suggest that there are systematic differences among countries that are worthy of study.
The current report describes patient and provider attitudes toward insulin therapy and their correlates based on data from a large multinational study. We examine the degree to which providers' tendency to delay insulin therapy is associated with general orientation toward prescribing blood glucose–lowering agents, specific beliefs about insulin therapy, and perceptions of patient attitudes toward insulin. We also examine the degree to which patient perceptions of insulin's benefits and self-blame for needing to initiate insulin therapy are associated with perceived diabetes severity (control and complications), diabetes-related emotional distress, adherence to self-care recommendations, and quality of the patient-provider relationship. We also consider differences among countries in patient and provider resistance to initiating insulin therapy.
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