The present research explored the frequency and helpfulness of HCPs’ statements and actions that helped adults with T2DM in the UK who were initially reluctant to start insulin therapy eventually make a favourable decision. It was observed in the global survey that the clinicians utilised a variety of strategies to help patients overcome the insulin initiation resistance. However, participants perceived not all actions as equally helpful .
In the UK subgroup, the majority of the most helpful statements and/or actions were related to the factor “demonstration of the injection process” identified in the overall study and considered to be directed towards reducing fears and discomfort about the injection procedure. Of interest, this factor also presented the highest mean levels of helpfulness in the overall study . These statements and actions included the following: HCP talking the patient through the whole process on exactly how to take insulin, HCP showing the patient an insulin pen, HCP helping the patient try an injection himself/herself during their consultation and HCP helping the patient see how simple it was to inject insulin. These actions were reported as occurring more frequently. Additionally, these strategies were consistent with clinical recommendations commonly utilised for addressing PIR, for example, the importance of educating patients on injection technique at the time of insulin initiation (such as simple and straightforward instructions on when and how to take an injection, including site rotation and disposal) . Further, these data correlate with the findings from the TRIAD (Translating Research Into Action for Diabetes Insulin Starts) project, where patients who did not begin insulin therapy commonly reported limited/a lack of self-management training .
Other strategies that extensively helped participants were HCPs explaining that insulin was a natural substance that the body needed, encouraging patients to contact them immediately in case of any problems/questions, presenting to patients their blood glucose numbers and helping them understand that their diabetes was not under control and needing action. A recent study in Canada in patients with T2DM not achieving recommended glycaemic targets provided similar practical recommendations to HCPs, highlighting that explaining the benefits of insulin therapy, allaying patients’ concerns and collaborating with patients to explain the need for insulin were the key strategies to help patients overcome PIR . Other studies that underlined the importance of HCP–patient collaboration to develop a shared action plan reported not only positive patient insulin initiation experiences but also improved concordance with insulin therapy [17, 20].
Consistent with the findings in the overall study report, HCPs’ statements and actions linked to an authoritarian communication approach that was identified in the overall study, such as HCPs repeatedly trying to convince patients to start insulin, were observed to be least helpful in the UK . These actions were reported to occur less frequently and were broadly considered to result in poorer outcomes.
To date, various studies in the UK have evaluated the evidence and reasons for clinical inertia and underlined the importance of self-management educational programmes and clinician education and training [21, 22]. However this is the first study specific to adults with T2DM in the UK which provides evidence-based clinical recommendations/strategies to HCPs for addressing PIR in such patients.
The study does have some limitations. Owing to the nature of the study, participants were recruited from online panels and through public diabetes website announcements; we could assume these adults were possibly more involved with their condition than the usual patient population in the country would be. Thus, the group of adults who showed willingness to participate in the study were possibly not the most reluctant group of patients, and the findings may not be completely true to the entire community with T2DM exhibiting PIR. Bias may also have been introduced as a result of the differing levels of compensation offered to participants dependent on their mode of recruitment. However, as 69% of UK participants in the study were recruited through the same non-payment method, any bias due to receipt of incentives is likely to be limited. Further, these participants were younger than expected so might not be representative of all adults with T2DM in the UK. The data for events that occurred previously were self-reported and might be subject to recall bias. The verification of variables such as the presence of T2DM and the time of insulin initiation using chart records was not carried out. Moreover, the descriptive design of the study may not adjust for plausible confounders. Finally, the small sample size could have biased the results, undermining the external validity of the study, and results should be interpreted with caution. Replicating the study in a sufficiently large and diverse sample is warranted.