Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help—insights from Norwegian general practice

• Published in: Scandinavian journal of primary health care Vol. 42; no. 1; pp. 132 - 143
• Main Authors: Mdala, Ibrahimu, Nøkleby, Kjersti, Berg, Tore Julsrud, Cooper, John, Sandberg, Sverre, Løvaas, Karianne Fjeld, Claudi, Tor, Jenum, Anne Karen, Buhl, Esben Selmer
• Format: Journal Article
• Language: English
• Published: United States Taylor & Francis LLC 01.03.2024; Taylor & Francis; Taylor & Francis Group
• Subjects: Access; basal insulin; Blood Glucose; Delayed; Diabetes; Diabetes Mellitus, Type 2 - therapy; General Practice; Graphs; Humans; Hypoglycemic Agents - therapeutic use; Insulin; insulin initiation; Norway; Patients; Primary care; Retrospective Studies; Staffing; therapeutic inertia; Type 2 diabetes mellitus; Norway; basal insulin; general practice; insulin initiation; primary care; Type 2 diabetes mellitus; diabetes nurse; therapeutic inertia
• ISSN: 0281-3432; 1502-7724; 1502-7724
• DOI: 10.1080/02813432.2023.2296118

: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D). This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA <7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments. Insulin naïve patients with 'timely' (  = 294), 'postponed' (  = 219) or 'no need of' (  = 3,781) basal insulin-initiation, respectively. HbA [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome. In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.