title: Clinical inertia in patients with T2DM requiring insulin in family practice.
abstract: OBJECTIVE
  To describe the clinical status of patients with type 2 diabetes mellitus (T2DM) in the primary care setting at insulin initiation and during follow-up, and to assess the efficacy of insulin initiation and intensification.
  
  
  METHODS
  Ontario FPs from the IMS Health database who had prescribed insulin at least once in the 12 months before November 2006 were randomly selected to receive an invitation to participate. Eligible and consenting FPs completed a questionnaire for each of up to 10 consecutive eligible patients. Patient data were recorded from 3 time points.
  
  
  METHODS
  Family practices in Ontario, Canada.
  
  
  METHODS
  One hundred and nine FPs and 379 of their T2DM patients taking insulin (with or without oral agents).
  
  
  METHODS
  Glycated hemoglobin (HbA₁(c)) levels, daily insulin dose, and use of concomitant oral agents at insulin initiation and 2 subsequent visits.
  
  
  RESULTS
  Data from each patient were obtained on insulin initiation and intensification, glycemic control, further pharmacologic therapy, and related complications. Mean time from diagnosis of T2DM to insulin initiation was 9.2 years. Mean HbA₁(c) values were 9.5% before insulin initiation, 8.1% at visit 2 (median 1.2 years later), and 7.9% at visit 3 (median 3.9 years after initiation). Mean insulin dose was 24 units at initiation, 48 units at visit 2, and 65 units at visit 3. At visit 3, 20% of patients continued to have very poor glycemic control (HbA₁(c) > 9.0%). With the exception of a decrease in sulfonylurea use, concomitant use of oral antihyperglycemic agents remained static over time.
  
  
  CONCLUSIONS
  Even in patients identified as being sufficiently high risk to warrant insulin therapy, a clinical care gap exists in physician efforts to achieve and sustain recommended HbA₁(c) target levels. Family physicians need strategies to facilitate earlier initiation and ongoing intensification of insulin therapy.
authors.affiliation: Department of Family Medicine and Family Medicine Studies, Schulich School of Medicine and Dentistry, University of Western Ontario, London. sharris1@uwo.ca
authors.forename: Stewart B
authors.initials: SB
authors.lastname: Harris
authors.forename: Jovana
authors.initials: J
authors.lastname: Kapor
authors.forename: Cynthia N
authors.initials: CN
authors.lastname: Lank
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Willan
authors.forename: Tricia
authors.initials: T
authors.lastname: Houston
mesh_terms: D000328:Adult; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D005194:Family Practice; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use*; D016015:Logistic Models; D008875:Middle Aged; D009864:Ontario; D058007:Physicians, Primary Care; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D011795:Surveys and Questionnaires
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin