Getting under the skin of clinical inertia in insulin initiation: the Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project.
The purpose of this cross-sectional study is to explore primary care providers' (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs.



As part of the Translating Research Into Action for Diabetes study, the authors conducted structured interviews in health systems in Indiana, New Jersey, and California, asking PCPs about the importance of insulin initiation and factors affecting this decision. The authors calculated proportions choosing each multiple-choice response option and listed the most frequently offered open-ended response categories.



Among 83 PCPs, 45% were women; 60% were white; and they averaged 13.4 years in practice. Four-fifths of PCPs endorsed guideline-concordant glycemic targets, but 54% individualized targets based on patient age, life expectancy, medical comorbidities, self-management capacity, and willingness. Most (64%) reported that many patients were resistant to new oral or insulin therapies due to fears about the therapy and what it meant about their disease progression. Two-thirds (64%) cited patient resistance as a barrier to insulin initiation, and 43% cited problems with patient self-management, including cognitive or mental health issues, dexterity, or ability to adhere. Eighty percent felt that patient nonadherence would dissuade them from initiating insulin at least some of the time.



PCPs perceived that patient resistance and poor self- management skills were significant barriers to initiating insulin. Future studies should investigate whether systems-level interventions to improve patient-provider communication about insulin and enhance providers' perceptions of patient self-management capacity can increase guideline-concordant, patient-centered insulin initiation.
The General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, California (Dr Ratanawongsa, Dr Schillinger)
Neda
N
Ratanawongsa
Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey (Dr Crosson)
Jesse C
JC
Crosson
The General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, California (Dr Ratanawongsa, Dr Schillinger)|California Diabetes Program, California Department of Public Health, San Francisco, California (Dr Schillinger)
Dean
D
Schillinger
Epidemiology and Health Services Research, Division of Research, Kaiser Permanente, Oakland, California (Dr Karter)
Andrew J
AJ
Karter
Division of Biostatistics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana (Dr Saha)
Chandan K
CK
Saha
Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana (Dr Marrero)
David G
DG
Marrero
D002140:California / Q000453:epidemiology; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000453:epidemiology / Q000523:psychology; D005260:Female; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007196:Indiana / Q000453:epidemiology; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D009515:New Jersey / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011320:Primary Health Care; D057170:Translational Research, Biomedical / Q000639:trends; D016903:Drug Monitoring
D007004:Hypoglycemic Agents; D007328:Insulin