Why Physicians Do Not Initiate Insulin Earlier

Reasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. So, this study set out to understand the barriers.

Researchers surveyed insulin-naïve patients with poorly controlled Type 2 diabetes, already treated with two or more oral agents who were recently prescribed insulin. They compared responses for respondents prescribed, but never initiating, insulin (n = 69) with those dispensed insulin (n = 100).

The results showed that the subjects failing to initiate prescribed insulin commonly reported misconceptions regarding insulin risk (35% believed that insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death), plans to instead work harder on behavioral goals, sense of personal failure, low self-efficacy, injection phobia, hypoglycemia concerns, negative impact on social life and job, inadequate health literacy, health care provider inadequately explaining risks/benefits, and limited insulin self-management training.

Nonadherent patients often blamed themselves, believing prior poor self-management caused the current need for insulin and erroneously conceptualized insulin as itself the cause of future complications. These patient-level findings are consistent with previous studies of attitudes about insulin. Not previously reported is the finding that nonadherent patients frequently felt their provider had not adequately explained the risks and benefits of insulin. 

The importance of provider communication is underscored by the association between insulin initiation and health literacy. Primary nonadherence likely also reflects inadequate shared decision making or lack of self-management training. Interventions for PIR need to address both provider- and system-level factors.

Diabetes CareApril 2010 vol. 33 no. 4 733-735