Insulin initiation in adults: evidence based or context driven?

Aim. To describe insulin initiation practices across the United Kingdom (UK) and identify factors influencing current practice.Background. The number of people commencing insulin therapy has escalated in recent years; due to increased incidence of diabetes and the evidence that improvements in glycaemic control can reduce and delay the onset of diabetic complications. However, the process of insulin initiation is not well described and the optimal way to start insulin therapy is unclear. There is currently a strong emphasis on moving diabetes care from secondary to primary care and this change in policy may also influence insulin initiation.Methods. A quantitative, cross-sectional, nationwide survey of diabetes specialist nurses (DSNs) and practice nurses (PNs) was completed in 2006. Data were gathered using a postal questionnaire, 1310 were returned (37·7% response rate).Results. Almost all DSNs working in secondary, or across primary and secondary, care initiate insulin in people with type 1 diabetes, but only 37·7% of DSNs working in primary care or 2·5% of PNs (p <0·001). Most DSNs initiate insulin in adults with type 2 diabetes compared with only 37·7% of PNs (p <0·001). Only 23·5% of respondents initiate insulin for those with gestational diabetes (GD), most working in secondary care (p <0·001). The most commonly used insulin regimen was multiple injection in type 1 diabetes (43·9%), a twice-daily mixture (19·2%) and night only basal insulin (17·9%) in type 2 diabetes and multiple injection in GD (46·8%). Analogue insulins were more frequently used than non-analogues in type 1 and 2 diabetes but almost equally in those with GD.Conclusion. Despite the drive for much more diabetes care to be delivered in primary care insulin initiation remains largely the province of secondary care, and regardless of the contested nature of the evidence base, analogue insulins are widely used.Relevance to clinical practice. The focus of this study was on one aspect of diabetes care (insulin initiation), however the findings illustrate that whilst policy relating to the care of people with a long-term condition such as diabetes may change, the practice implications in terms of community provision and availability of appropriate expertise are complex.