The failing diabetic patient in primary care
Diabetes is a progressive disorder. The majority of people with Type 2 diabetes are likely to require more intensive treatment regimes over time and a substantial proportion have sub-optimal glycaemic control as measured by glycated haemoglobin (HbA1c). For these people a change to insulin is a possible option. However, this requires a major step for most people and their clinicians. The aim of this research was to ascertain the size of the problem, to obtain the views and perceptions about diabetes management of people with Type 2 diabetes and their carers' (including diabetic nurses and general practitioners), to establish a consensus based management regime, and to ascertain the possible impact on diabetes specific quality of life of the commencement of insulin. This thesis used four methodologies. An existing primary care database was analysed to assess the scale of the problem of the poorly controlled Type 2 diabetic population in primary care. Qualitative research using focus groups was used to explore the beliefs of patients and clinicians towards diabetes and in particular the commencement of insulin in those failing on oral treatment. A mixed consensus group was used to describe a care pathway for these patients. Finally, in a cohort of people with Type 2 diabetes failing on oral therapy, a disease specific questionnaire was used to ascertain quality of life issues around the initiation of insulin. Main findings:1) Over half of people with Type 2 diabetes were in poor glycaemic control, defined as an HbAlc ˃8%. 2) People with Type 2 diabetes viewed diabetes as a "mild disease", using their experience and the social effects of living with their diabetes to monitor progress. They saw insulin as a last resort to be delayed as long as possible.3) Clinicians felt the majority of diabetes care could and should be provided in the community with an active management approach. Non-compliance with treatment was seen as an issue. Insulin was viewed positively while, at the same time, seen as being actively resisted by patients. The increase in resource and workload around insulin initiation was a major concern. 4) Much uncertainty remained regarding the management of the failing diabetic patient. The value of early insulin treatment was questioned for the asymptomatic patient. Shared decision-making was advocated but problems around risk/benefit information and lack of resources in both primary and secondary care were highlighted. 5) Insulin treatment in a cohort of people with Type 2 diabetes in poor glycaemic control on oral hypoglycaemic agents resulted in a modest but significant improvement in glycaemic control in routine care. Insulin initiation did not result in a change in quality of life. Patients' satisfaction with their tablet treatment was high but increased significantly on starting insulin therapy. However, these conclusions were limited by low study numbers from poor study recruitment. Conclusions Improving the care of people with poorly controlled Type 2 diabetes who are on maximal oral treatment is not straightforward and represents large resource and workload issues. Patient and clinician beliefs affect management and are not always currently sought and addressed. The benefits of early, more aggressive treatment with insulin need to be better quantified and information better presented to allow patient participation in decision making: glycaemic control is not the only factor that needs to be considered. A large gap in resources to achieve this was identified. The effect of insulin treatment on quality of life unfortunately has not been adequately answered in this research due to low participant numbers.