Dutch Institute for Rational Use of Medicine, Churchilllaan 11, 3527 GV, Utrecht, the Netherlands.
Dept. of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, the Netherlands.
BMC Prim Care. 2022 Jun 13;23(1):150. doi: 10.1186/s12875-022-01760-5.
Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines.
Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence.
Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified.
The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.
荷兰的一般实践中，指南的遵循率通常很高。然而，给 2 型糖尿病患者开具的胰岛素往往不符合指南建议，指南建议首选 NPH 胰岛素，并劝阻使用新型胰岛素。这项定性研究旨在确定初级保健医疗保健专业人员开具不符合指南建议的胰岛素的原因。
组织初级保健从业者的数字焦点小组。根据从文献和预先专家讨论中获得的首选胰岛素的原因，制定了一个主题清单。讨论进行了视频和音频记录，逐字转录并使用归纳和演绎代码进行编码。代码被分类到现有的知识、态度和行为模型中，以解释指南不依从的原因。
组织了四个焦点小组，其中包括 11 名全科医生、12 名执业护士、6 名药剂师、4 名糖尿病护士和 2 名护士从业者。非推荐胰岛素的处方主要受态度领域的论点驱动。缺乏与指南的一致性是最突出的类别。这些观点中的大多数并不反映普遍不同意指南建议，而是关于非推荐胰岛素的优势，根据医疗保健专业人员的说法，这使得这些胰岛素更适用于特定患者。认为推荐胰岛素效果较差、对其他胰岛素的积极经验以及制药公司的营销也是不推荐推荐胰岛素的态度相关障碍。在态度领域还确定了另一个类别，即同一实践中的医疗保健专业人员之间政策缺乏一致性。只确定了少数外部障碍，主要集中在阻止使用推荐胰岛素的患者特征、可用的相互矛盾的指南以及其他主要是二级保健的医疗保健提供者启动非推荐胰岛素。没有发现与知识相关的障碍。
初级保健中开具非推荐胰岛素主要是由于缺乏对指南建议的一致意见和对证据的不同解释。这些见解可用于开发干预措施，以激励初级保健从业者开具符合指南建议的胰岛素。
