Post-Basal Insulin Intensification and Healthcare Resource Use in Type 2 Diabetes: A Web-Based Physician Survey in the United States and United Kingdom

This study adds to previous research on the intensification process from basal insulin to more complex regimens in T2D patients from the perspective of physicians [17]. Consistent with prior research [15, 19], the findings suggest that the complexity of the basal–bolus regimen, adding additional injections, and negative side effects such as weight gain and hypoglycemia are key patient barriers to intensification to basal–bolus. For intensification to basal in combination with GLP-1, adding additional injections, negative side effects, and insurance coverage/costs were frequently reported reasons for patient refusal to intensify with GLP-1, which is also in line with prior research [19]. Such challenges may result in patient reluctance to intensify, medication non-adherence, and non-persistence, all of which may serve as barriers to timely diabetes control.

While these challenges with intensification to basal–bolus and basal in combination with GLP-1 regimens have been previously studied, this is the first study to look at the healthcare resources and time needed for intensification, as well as the referral process. Results suggest that the intensification process to complex regimens is time-consuming and requires substantial use of healthcare resources. The basal–bolus intensification process required 7.0 HCP visits, on average, and lasted approximately 30.1 weeks. The intensification process to basal combined with GLP-1 took an average of 5.7 HCP visits and about 23.5 weeks. The relatively high number of HCP visits and length of time for intensification with GLP-1 are somewhat surprising given that intensifying with GLP-1 is theoretically less complex than intensifying to basal–bolus. The substantial use of healthcare resources for intensification have cost implications and may pose financial burdens on both patients and payers.

Additionally, the lengthy time to treatment intensification suggests that T2D patients may experience long periods of time in which their diabetes is uncontrolled before their regimen is fully intensified. When referral to a specialist is required for intensification, the wait time for an appointment adds an average of 8.4 additional weeks to the intensification process. This means an average intensification time of 38.5 weeks (approximately 9 months) for basal–bolus therapy and 31.9 weeks (approximately 8 months) for intensification to basal insulin in combination with GLP-1. Such delays to post-basal insulin intensification are concerning given the importance of timely blood glucose control to reduce risks of long-term diabetes-related complications [1, 3]. Even when T2D patients are intensified successfully to basal–bolus therapy or basal insulin in combination with GLP-1, physicians reported that medication non-adherence and non-persistence were frequent problems and that some intensified patients do not reach their HbA1c targets, all of which are well-known challenges to T2D management [20, 21, 22].

In sum, the study findings suggest that more simplified treatment options for post-basal insulin intensification may help reduce the time and healthcare resources required for intensification. Additionally, the results suggest that less complex treatments would also address patient concerns related to frequent injections and regimen complexity, which may improve medication adherence and persistence, and ultimately improve diabetes control. Less complex treatment options may also reduce the need for referrals to specialists for intensification. Recent research suggests that a new treatment option for post-basal insulin intensification, which includes a less complex regimen and fewer injections compared to basal–bolus therapy or basal insulin in combination with GLP-1, reduces the time and healthcare resources necessary for intensification [17]. Further, patient and physician education may also help reduce the number of HCP visits and time required for post-basal insulin intensification.

Several study limitations should be considered when interpreting results. The reliance on physician recall of experiences and perceptions, rather than a systematic review of chart data, means there is the potential for recall bias. Moreover, asking physicians to report on “example” patients with more “typical” or “average” experiences does not capture the broad range of intensification experiences that patients may have. A systematic review of chart data may provide more robust and complete information on the post-basal insulin intensification process in T2D.

Although the physician panels used to recruit physicians for the survey were designed to be representative of physicians in each country, the possibility of selection bias also cannot be ruled out. Further, some overlap may exist in the reported time and healthcare resources needed for intensification training and titration. Although the survey questions were designed to avoid such overlap, it is possible that some HCP visits include continued training, as well as titration. Finally, results may not be generalizable to other countries or in differing healthcare systems outside of the UK and USA. Future research might investigate how the healthcare resources and time required for post-basal insulin intensification, as well as the referral process, may differ in other healthcare systems.