Agarwal Gina, Nair Kalpana, Cosby Jarold, Dolovich Lisa, Levine Mitchell, Kaczorowski Janusz, Butler Chris, Burns Sheri
Department of Family Medicine, McMaster University, Centre for Evaluation of Medicines, St Joseph's Hospital, Hamilton, ON, Canada.
Br J Gen Pract. 2008 Aug;58(553):569-75. doi: 10.3399/bjgp08X319639.
Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people.
To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes.
Qualitative individual interviews using a grounded theory approach.
Primary care.
A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin.
Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing.
GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.
有证据表明，老年人中胰岛素的处方量不足。造成这种情况的一些原因包括医生对潜在副作用的担忧或患者对胰岛素的抵触。然而，总体而言，对于全科医生如何做出与老年人胰岛素处方相关的决策知之甚少。
探讨全科医生在治疗老年2型糖尿病患者时处方决策的过程和依据。
采用扎根理论方法进行定性个体访谈。
初级保健机构。
进行主题分析，以确定反映影响胰岛素处方因素的主题。
安大略省21名在职全科医生完成了访谈。确定了影响老年患者胰岛素处方的七个因素：全科医生对老年人的看法；全科医生对糖尿病及其管理的看法；评估所需治疗强度；胰岛素治疗准备的必要性；有无来自非正式或正式医疗服务提供者的支持；对管理复杂性的无奈；以及全科医生胰岛素给药的经验。尽管全科医生表示会考虑上述因素来开具胰岛素处方，但在预期的处方方法和自我报告的处方之间存在差异。
全科医生开具（或不开具）胰岛素处方的依据受从业者相关因素和患者相关因素的共同影响。全科医生预期的和实际的处方因他们对每个患者情况的评估而异。为了改善越来越多老年2型糖尿病患者的处方情况，需要对全科医生进行更多教育、提供专科支持并利用专职医疗人员。
