Clinical inertia in patients with T2DM requiring insulin in family practice

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. DESIGN 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. SETTING Family practices in Ontario, Canada. PARTICIPANTS One hundred and nine FPs and 379 of their T2DM patients taking insulin (with or without oral agents). MAIN OUTCOME MEASURES Glycated hemoglobin (HbA(1c)) 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 HbA(1c) 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 (HbA(1c) > 9.0%). With the exception of a decrease in sulfonylurea use, concomitant use of oral antihyperglycemic agents remained static over time. CONCLUSION 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 HbA(1c) target levels. Family physicians need strategies to facilitate earlier initiation and ongoing intensification of insulin therapy.