Engaging GPs in insulin therapy initiation: a qualitative study evaluating a support program in the Belgian context

Abstract

BackgroundA program supporting the initiation of insulin therapy in primary care was introduced in Belgium, as part of a larger quality improvement project on diabetes care. This paper reports on a study exploring factors influencing the engagement of general practitioners (GPs) in insulin therapy initiation (research question 1) and exploring factors relevant for future program development (research question 2).MethodsWe have used semi-structured interviews to answer the first research question: two focus group interviews with GPs who had at least one patient in the insulin initiation program and 20 one-to-one interviews with GPs who were not regular users of the overall support program in the region. To explore factors relevant for future program development, the data from the GPs were triangulated with data obtained from individual interviews with patients (n = 10), the diabetes nurse educator (DNE) and the specialist involved in the program, and data extracted from meeting reports evaluating the insulin initiation support program.ResultsWe found differences between GPs engaged and those not engaged in insulin initiation in attitude, subjective norm and perceived behavioural control regarding insulin initiation. In general the support program was evaluated in a positive way by users of the program. Some aspects need further consideration: job boundaries between the DNE and GPs, job boundaries between GPs and specialists, protocol adherence and limited case load.ConclusionThe study shows that the transition of insulin initiation from secondary care to the primary care setting is a challenge. Although a support program addressing known barriers to insulin initiation was provided, a substantial number of GPs were reluctant to engage in this aspect of care. Important issues for future program development are: an interdisciplinary approach to job clarification, a dynamic approach to the integration of expertise in primary care and feedback on protocol adherence.Trial registrationClinicalTrials.gov Identifier: NCT00824499

Instauration d’une insulinothérapie chez le patient diabétique de type 2 en médecine générale : Comparaison de l’étude belge InsuStar avec quelques études françaises et internationales

“…Dans une autre étude observationnelle récente, menée également au Royaume-Uni (n = 11 696), un long délai (médiane de 3,7 années) a été objectivé avant qu'une intensification d'un traitement comprenant uniquement une insuline basale soit réalisée chez des patients DT2 avec un taux d'HbA 1c > 7,5 % [45]. Une optimisation de la prise en charge du patient DT2 nécessite probablement une meilleure coordination entre MG et médecins spécialistes, avec l'aide d'infirmiers ou infirmières spécialisés en diabétologie jouant le rôle d'interface, comme cela a été démontré dans une étude pilote en Belgique [46], ainsi que dans d'autres pays [47]. Le guide de parcours de soins du DT2 de l'adulte proposé par la Haute Autorité de Santé (HAS) en France, plaide pour une prise en charge intégrée et coordonnée [48].…”

Metaphors of Interdisciplinary Collaboration to Overcome the Theory-Practice Gap when Transitioning from RN to Advanced Practice Nurses

“…Only once GPs are satisfied they can relinquish certain duties and care activities to APNs can the APNs have freedom to operate within their scope of practice [11]. Such freedom enables continued skill building and competence as in the case of diabetic nurse educators whose skills in insulin initiation and titration are found superior to those of a GP [12].…”

“…Even when supervised by NPs in the initial stages of their training, GP residents were still unclear about the NP"s scope of practice [13]; experienced GPs report the APN scope of practice as "ill-defined" [7], [12], [14]. This lack of a clear understanding of the role and responsibilities of the APN acts as a boundary between the two practice professions, with physicians losing interest in the position and becoming disconnected from the APN.…”

“…For example, some physicians were uncomfortable with nurses making a diagnosis [15] and with losing control over treatment decisions [12]. Many NPs were found reluctant to fully utilise prescribing rights because they considered themselves to be nurses first and did not wish to be perceived as elitist and acting like a physician [14].…”

“…An uneasy tension developed when APNs wanted increased stature within the general practice [12]- [13], [15]- [18] while GPs were the sole arbiters of what the nurse could or could not do. Disagreement on the place of the APN in the general practice milieu and how to best utilize this model of care was reported [12]- [13], [15], [17], [21]- [22].…”