title: Factors that drive insulin-dosing decisions of diabetes care providers: a vignette-based study in the Netherlands.
abstract: OBJECTIVE
  To test how certain patient factors would influence the decision of Dutch care providers regarding insulin dose adjustments. We hypothesize that some of these decisions would diverge from recent evidence and consensus statements.
  
  
  METHODS
  We developed narrative vignettes describing clinical scenarios of patients receiving basal insulin therapy. For each vignette, the respondents were asked to indicate whether they would advise a change in insulin dose. A total of 520 paper questionnaires were distributed among physicians and nurses in primary and secondary care in the Netherlands. Multivariate linear and logistic regression analyses were performed to identify factors associated with dosing decisions.
  
  
  RESULTS
  A total of 190 (37%) questionnaires were returned. In cases of a severe rather than mild hypoglycaemic event, care providers were nearly five times more likely to decrease the dose (odds ratio 4.77, 95% CI 1.65-13.75). Care providers were six times more likely to increase the dose when the patient's current dose was low (30 units) rather than high (90 units) (odds ratio 6.38, 95% CI 3.04-13.37). The plasma glucose concentration during a hypoglycaemic event and a known history of cardiovascular disease did not influence the care providers' dosing decisions.
  
  
  CONCLUSIONS
  Evidence regarding the optimum insulin titration is not always translated into clinical practice. When formulating guidelines, misconceptions should be identified and addressed.
authors.affiliation: Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands; Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: A C R
authors.initials: AC
authors.lastname: Simon
authors.forename: J E
authors.initials: JE
authors.lastname: Schopman
authors.forename: J B L
authors.initials: JB
authors.lastname: Hoekstra
authors.forename: A
authors.initials: A
authors.lastname: Abu-Hanna
authors.forename: V E A
authors.initials: VE
authors.lastname: Gerdes
authors.forename: N
authors.initials: N
authors.lastname: Peek
authors.forename: F
authors.initials: F
authors.lastname: Holleman
mesh_terms: D000328:Adult; D000465:Algorithms; D001291:Attitude of Health Personnel; D003657:Decision Making; D003922:Diabetes Mellitus, Type 1 / Q000188:drug therapy* / Q000453:epidemiology; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000453:epidemiology; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D055317:Evidence-Based Practice; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007003:Hypoglycemia / Q000517:prevention & control*; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007328:Insulin / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin