Physicians’ Perspectives of Barriers to Insulin Initiation for Adults with Type 2 Diabetes Mellitus in Primary Health Care Centers (PHCCs), Tabouk Province - Kingdom of Saudi Arabia (KSA)

Abstract

Aim: The goal of this study is to explore the family physicians’ perspectives of the barriers in initiating insulin for adult patients with Type 2 diabetes mellitus (T2DM) in their primary health care settings. Background: Insulin therapy often becomes necessary when oral anti-hyperglycemic agents are not enough, no longer effective or even as an initial choice. Timely insulin initiation was noticed to be a clinical problem among people with type 2 diabetes mellitus (T2DM) registered in primary health care centers (PHCCs) of Tabouk Province, KSA. Tackling this inertia or insulinophobia is a challenge in order to delay or prevent serious complications of uncontrolled diabetes. Our study and many other studies indicated that this therapeutic inertia is inappropriately due to many patient, system and physician-related factors. The present study aimed to investigate physicians’ perspectives of barriers to insulin initiation for adults with T2DM registered in PHCCs, Tabouk Province - KSA and to identify opportunities for better outcomes. Materials and Methods: This is a cross sectional study where 102 primary health care physicians (PHCPs) (58 females and 44 males) from multi PHCCs in Tabouk Health Province – Kingdom of Saudi Arabia (KSA), responded correctly to online reliable self-administered questionnaire (Cronbach alpha of 0.77344) to address their perspectives of barriers to insulin initiation for adult patients with T2DM. All participants were physicians attending PHCCs with well-equipped diabetes care clinics. Data were collected during a period from 6th – 17th June 2021. Participants included 11 (10.8%) family medicine consultants, 14 (13.7%) family medicine specialists and 77 (75.5%) general physicians. Results: 68.6 of the study participants had barriers in initiating insulin for their patients with T2DM. A significant statistical disproportional correlation was found between the level of specialty and the rate of reporting barriers to insulin initiation (P<0.001). The top 10 listed barriers included the following: patients’ refusal to initiate insulin (71.4%), physicians’ fear of hypoglycemia (51.4%), inability of patients to perform home blood glucose monitoring (HMGM) (50%), physicians have no access to second opinion (44.3%), insufficient educational courses for physicians (37.1%), no family support for patients (34.3%), no clear MOH circular to support physicians’ initiation of insulin at PHCCs (28.6%) , insufficient hypoglycemic medications at PHCCs (25,7%), inability of patients to manage hypoglycemia (24.3%), and patients’ noncompliance to insulin regimen (24.3%). Conclusion: Despite the free of cost availability of all types of insulin, including the safest and peak less ultra-long (degludec) and long (Glargine), the availability of free of cost glucometers for all people with diabetes, the presence of a well-equipped diabetes clinic at every PHCC, the long list of guidelines and educational courses as well as an appointment system with electronic health information system (HIS), insulin inertia is a common problem among PHCPs working in Tabouk Health Region. Key words: Barriers, insulin initiation, insulin, primary health care, type 2 diabetes mellitus.