This is the first study to comprehensively examine the prescribing practices and factors of influence of specialist diabetes healthcare professionals regarding insulin initiation in T2D across Central and South-Eastern European countries. In this large (n = 211) cohort, we show a high prevalence of clinical inertia, with only ~ 10% of prescribers initiating insulin therapy at the recommended HbA1c threshold of 7–7.9% (53–63 mmol/mol). Moreover, almost half the healthcare professionals sampled were orientated towards initiating insulin therapy in patients if an HbA1c threshold of ≥ 9.0% (≥ 75 mmol/mol) was met, with a further ~ 10% only initiating insulin when a threshold of ≥ 10.0% (≥ 86 mmol/mol) was reached. Further, we highlight substantial regional differences in the clinical approach to insulin initiation in T2D. For example, almost 80% of respondents from Bulgaria would only initiate insulin therapy in T2D at an HbA1c a threshold of ≥ 9.0% (≥ 75 mmol/mol), of which ~ 95% would not initiate insulin until a threshold of ≥ 10.0% (≥ 86 mmol/mol) was reached, compared to < 15% of prescribers in Slovenia. These results indicate that only the most poorly controlled patients, as opposed to all patients with evidence of inadequate glycaemic control, are likely to receive timely insulin initiation and that this is in part dependent upon country of residence. Our findings compliment and extend other large multinational studies reporting clinical inertia with regards to insulin initiation in T2D in Europe and elsewhere [15, 16].
Preference of basal insulin as the initial choice of insulin therapy is supported by the observation that basal insulin is often judged easier to use and with less risk of hypoglycaemia and weight gain. Further, although a premixed and a basal-bolus regimen have been found to yield greater reductions in HbA1c, compared to basal-only therapy, both are associated with weight gain, increased hypoglycaemia, and inconvenience [17, 18].
Previously, physician-, patient-, and healthcare system-related factors have been identified as contributing factors to clinical inertia in insulin initiation . In our study, we identified consistent patterns in factors influencing clinical decision-making across the region. Our study participants ranked health insurance regulations and constraints as the most important factor influencing prescription practices, with clinical guidelines ranked as the least important factor. Further, patient distress was highlighted as the most important factor influencing clinical decisions, whereas risk of hypoglycaemia and potential weight gain as the least important factors. In the countries we sampled from, there is restricted regional availability of blood glucose self-monitoring (BGSM) reimbursement , and increasing BGSM increases the patient burden of managing T2D .
Our data indicates that healthcare professionals within the region turn primarily to peers and manufacturer information to guide and inform insulin initiation practices and that such practices are informed least from CME. Whereas some research has suggested that healthcare professionals perceive industry influence to be low , the reality is that the pharmaceutical industry is often a key source of information regarding new products and treatment options . Indeed, several studies have shown that physicians are susceptible to the pharmaceutical industry and interactions with pharmaceutical sale representatives and that this influences prescribing practices [24,25,26]. In our study, we cannot rule out that the availability of increasing numbers of non-insulin antidiabetic agents and a lack of accessible independent CME could foster a reluctance to use insulin among our healthcare professionals. The concept of evidence-based medicine, defined as the integration of best research evidence with clinical expertise and patient values, is considered an integral part of medical training and should be effectively integrated into independent, non-industry sponsored CME courses . Alarmingly however, our findings suggest that the majority of healthcare professionals within Central and South-Eastern European regions may not implement clinical guidelines and may not use evidence independent of industry to inform T2D treatment. As such, there is an urgent need to provide accessible CME courses independent of industry influence to prescribing specialist diabetes healthcare professionals within this region.
In conclusion, we provide new evidence which highlight a high level of clinical inertia regarding insulin initiation in T2D by prescribing diabetes specialist healthcare professionals in Central and South-Eastern Europe. We provide valuable insight into the factors influencing prescribing practices and clinical decision-making which highlight the urgent need to provide CME courses independent of industry in this region.