Understanding delay in starting insulin for type 2 diabetes
Frances Griffiths, Warwick Medical School (in collaboration with Michael Parchman,
University of Texas)
Research question
Why is there delay in starting insulin for type 2 diabetes when its initiation would improve
health?
Objectives
1. To derive a set of preliminary rules about initiation of insulin from detailed
qualitative analyses of longitudinal chart data of several hundred physician-patient
encounters extending over many years from 15 patients who were started on insulin
2. To develop a model or models of delay in starting insulin based on existing literature
and clinical expertise
3. To extract further data from NHS GP computerised clinical records system
4. To use the extracted data as a training set for further model development and testing
5. To estimate further data collection/retrieval requirements for further model
refinement.
Why it is interesting
People living with diabetes have better health and live longer if they control their blood sugar
with diet, exercise and appropriate medication. There are two types of diabetes. Type 1 needs
treatment with insulin from the time of diagnosis. Type 2 can be controlled with diet exercise
and tablets in its early stages but in time many need to start insulin. Studies show poor control
of glucose in a majority of patients with type 2 diabetes. A major cause is failure to initiate
insulin early enough. ‘Clinical inertia’ is often cited as an explanation and is defined as
recognition of a problem but a failure of the health professional to act. This failure to act was
found in 68% of 10,581 clinical encounters in a US study. It is suggested clinical inertia is
primarily a physician problem, for example use of soft reasons (such as other issues to attend
to, patient preference) to avoid starting insulin, overestimation of quality of care provided or
lack of knowledge. These hypotheses have not been tested. An alternative explanation may be
that inertia emerges from the interaction between patient and health professional. This project
is a UK/USA collaboration. The collaborators meet regularly by telephone/video-conferences.
The mini-project student will join with this collaboration.
Background to be assimilated
As a first step in exploring the alternative explanation, we have reviewed literature on
diabetes and insulin initiation, devised from our clinical experience possible ‘rules’ which
may delay starting insulin (including the ‘soft reasons’ above) and anonymised data collected
from clinical records of 15 patients with type 2 diabetes (in excel). This is all available to the
mini-project student. The clinical data is from diagnosis of diabetes to initiation of insulin (130 years) with between 20 and 300 time points in each case. At each time point the record
may include patient concerns, clinical assessment, laboratory test results and clinical
decisions/no decision. A basic understanding of the meaning of the clinical data could be
gained through reading literature for people living with diabetes. The students would be
introduced to the clinical data system for accessing further data.
Techniques required
Pattern identification, simple modeling of interactions over time, statistics for estimating
further data collection requirements.
Prospective deliverables
1. paper for publication in peer-reviewed health related journal
2. poster for presentation at an international conference
3. proposal for further research
Who will benefit?
This research has the potential to inform health care policy (such as guidelines and payment
systems in health care), health professional education and clinical practice (for example,
understanding how to limit clinical inertia appropriately) and ultimately patient health. It will
also increase the use of innovative methods of analysis within health related research.
Prospects for the mini-project leading to a PhD: very high. We have access to a large
volume of relevant clinical and research data.
Additional information
As the student will be accessing clinical data systems the student will need a Criminal
Records Bureau check and an honorary contract with the relevant primary care trust. These
will be arranged through the Medical School. The student will be required to fill in and
submit the CRB form and provide a CV for the honorary contract.