Primary Care Physician Belief About Insulin Initiation in Patients With Type 2 Diabetes, Article Critique Example

This very important study, conducted by Hayes, Fitzgerald & Jacobs (2008), was to provide insights into United States Physicians attitudes about initiating insulin in type 2 diabetes patient, with a view to find out whether there were consensus or the lack thereof in their beliefs, and if so, what they were, as well as to determine if there were associations between their shared characteristics such as age, beliefs, years of practice and the positions they hold with regard to initiating insulin therapy.

The study grew out of background research that showed that insulin, according to Brown, Nichols & Perry (2004), was the most effective therapy to achieve glycaemic goals in patients with type 2 diabetes, who were frequently found to maintain poor glycaemic control due to beliefs that increasing risk of serious complications existed on application and caused reluctance among US patients to accept treatment, as well as physicians unwillingness to initiate  treatment to their patients, based on their lack of conviction regarding the effectiveness of the therapy (Nathan, Buse, Davidson et al. (2008), Peyrot, Rubin, Lauritzen et al. (2005).

In the primary research done, the researchers chose their participants from an approved panel list of 40,000 physicians who had to qualify for the online survey by having more than three years clinical practice experience as well as having treated more than 10 patients with type 2 diabetes per week according to Hayes et al. (2008).

The sample size of 40,000 came from the authenticated American Medical Association master list of which 2552 board certified Family Practice, General practice or Internal Medicine Physicians were selected to participate, was large enough to make any objective analysis of the results obtained conclude that they are credible.

Additionally, physicians had to qualify before they could access the online survey, which was run for a limited time, during which these participants were offered an incentive of $60 as honorarium according to Hayes et al. (2008).

During the survey, according to Hayes et al (2008), the demographic status of each physician was first determined so that the glycaemic goals for each sub group could be isolated, while they are answering the 30 questions that were scientifically designed, using the five scale Likert type system, which allowed variations of the degrees of agreement or disagreement to each question to be captured in the data.

Item classification using priori as beliefs, frequency distribution determinations, one way variance analysis (ANOVA), Scheffe   post test, as well as the setting of alpha at <0.01 due to the large  number of statistical test, were used to conduct the entire statistical analysis of the data, according to Hayes et al. (2008).

In terms of issues of reliability and validity regarding the study, the capturing of the PCP response in 3-5 years, 6-10 years, 11-15 years, 16-30, and > 30 categories  and then comparing the mean and standard deviations among each other help to reduce bias as well as identify responses that were inconsistent with any pattern that was developing.

Significant differences between PCP in the 3-5 years of service level and those in the 16-30 range could be accounted for by the researchers, with the explanations that it was perhaps due to the experience gap as well as the currency or the lack thereof in the latest medical information available to both groups.

Additionally, the categorization of the number of patients sen on a weekly basis by the physicians into four categories , namely (a) 10-25, (b) 25-59, (c) 60-69, (d( > 100, and the use of mean and standard deviation to do make comparisons, helped to assess the significance of the attitudinal responses of these physicians towards their perceptions of their patients; thus contributing to the reliability and validity of the study in terms of the high quality data extracted.

The subjection of the physicians to an initial qualifying assessment before being allowed to access the survey, also contributed to ensuring the validity and reliability of the   study, because this aspect ensured only physicians meeting the standards could participate and the quality, confidence and integrity provided in getting information would be unquestionable during the analyses and assessments.

Validity and reliability were also ensured by Hayes et al. (2008), when the researchers subjected each category of physician’s responses in terms of years of practice and the number of patients seen on a weekly basis to the same statistical analyses after using the frequency distribution tool to separate them. At the end Hayes et al. (2008), could be able to identify significant and insignificant differences and further confirm that the process were meeting the goals and expectations desired.

The researchers maximized their efforts to bring reliability and validity to their program of study when they secured the services of two highly qualified and experience PCP and two authors of the Diabetes Attitude Scale (RMA, ITF), to work on their development panel. These personnel used their expertise to ensure the questions provided in the surveys were appropriate, relevant and significant in terms of generating the attitudinal responses that would enable the study to achieve its stated purposes at the end.

The study through the application of the Likert 5 scale rating system,  also provided variations in the answers given by the physicians, who with their different levels of experience and number of weekly patients seen, would have been exposed to  populations of type 2 diabetic patients  across Continental United States that  differ in their personalities, professional status, and socioeconomic backgrounds and would see their situations differently,  as they responded to their physicians during appointment sessions.

In exerting control on the study, the researchers conducted the survey for a limited time, provided access to qualified physicians who after completion could not regain access to make any changes, and constantly monitor the numerical status of the targeted population to ensure it was not exceeded but remain in compliance.

Hayes et al. (2008), at the end of the survey, could classify responses from Family Practice Physicians, Internal Medicine Specialists, and General Practice Physicians and used them to make conclusive statements as two whether they had consensus or not among them, as well as if there were association between their special characteristics such as age, years of experience and number of weekly patients seen and the attitudinal responses given.

The decision by Hayes et al. (2008), to employ the services of Harris Interactive; which was a large marketing firm with reputation and experience in the field ensured control was effectively brought into the study. The firm no doubt used its experiences to recommend the ideal sample size that would be representative of the information the researchers were intent on extracting regarding the behavior of United States physicians towards the initiation of insulin therapy to type 2 diabetic patients.

They also made provisions for the physicians who might be offended by the offer of $60 honorarium fee for participating in the study or for other ethical, technological or cultural reasons might be dissuaded from taking the survey to unsubscribe at any time. This no doubt ensured that practically only willing participants took part in the survey and most likely would volunteer their honest opinion towards the benefit of the medical profession, in terms of future possible change in their attitude with respect to how type 2 patients were being perceived and their responses to them.

Data compiled from the survey and analyzed revealed that the average age of the physicians was 46 years, 81 %v of them were male, and 52% of them had been in practice for more than 10 years according to Hayes et al. (2008). The results also 78% of the physicians had seen 10-59 patients per week and nearly 100% of them reported that patients less than 50 years had their HbAIc at ? 7% while 94% of those between 50-70 years  and 84% of the > 70 years old had achieved similar results, according to Hayes et al. (2008).

The measurement of shared beliefs achieved by the study showed that > 50 % of the physicians responses fell into the agree/disagree category. For the first 13 questions on the  survey physicians according to Hayes et al. (2008),  shared  similar beliefs about the barriers that injections posed to acceptance of the insulin, the prescribing of insulin, the importance of education concerning the drug initiation, the thinking that its benefits far outweighed the risk of hypoglycemia, the benefits of receiving medications prior to the development of complications, patients achieving improvements physically, the coping ability of patients once they are on insulin, the reluctance of patients on oral therapy to accept insulin prescription, and the statement that the initiation of insulin is one of the most difficult aspect of managing patients with type2 diabetes (Hayes et al. 2008).

With respect to the need for follow up for patients as a result of staff believing that the system too resource intensive, that training was required for insulin for effective insulin management, that there was the risk of weight gain and the fear of side effects, the study measurement of responses showed that the majority of physicians were in disagreement with these statements.

A lack of consensus among physicians according to Hayes et al (2008) was found in the study with respect to the concerns that most patients using insulin self monitor the blood glucose level properly, that they avoid injury by following the therapy recommendations, the belief that they will need therapy regardless of the treatment they adhere to, and that the time is needed for staff training was too much.

There was a significant outcome measured by the study, and this was with reference to the metabolic effects of insulin treatment on type 2 diabetes patient. There was confusion among the physicians regarding the true effect, in that 50 % were in agreement while the remaining 50% were in opposition, according to Hayes et al. (2008), and this reality may be the main reason why there has been reluctance on the part of American physicians to apply the therapy, bearing in mind that they can lose their medical licenses if successful lawsuits are brought against them.

The input of the female gender among the physicians were also measured and was shown to be significantly stronger than those of their male counterparts on the issue of oral therapy being preferred to the initiation, due to their patients in general beliefs their efforts in the latter were personal failures on their (patients) part according to Hayes et al. (2008).

Measurement of the impact of years of practice had on the attitude of physicians, showed that there were significant differences in beliefs among those with more than 15 years, who agreed more strongly than their lesser experience compatriots that their patients are able to more successfully cope with their insulin therapies, according to Hayes et al. (2008).

The situation was reversed somewhat, with regard to the need for follow up training according to Hayes et al. (2008), with the more experienced physicians strongly disagreeing for this need in comparison to those  having between 10 to 15 years. Physicians with less than 5 years experience had the highest disagreement levels with the statement that type 2 patients were in any way experiencing negative metabolic effects from the insulin therapy treatments from their perspective.

According to Hayes et al. (2008), generally the majority of physicians were in agreement that the benefits of using insulin to prevent or delay complications outweighed the risks of complication and weight gains, and on this basis the result from the study all things being equal, could be described as credible, despite the confusion and lack of consensus on the metabolic effects, especially among physicians having less that 5 years practice experience.

Conclusively, the study showed PCP’s shared some beliefs about insulin initiation but lack consensus on a number of other issues, particularly with respect to the risk versus benefit scenario. The belief that most patient felt better when after that have begun their insulin treatment program and can successfully manage its demands has been supported by the external studies like those that showed high levels patient satisfaction irrespective of the modal applications according to Bradley & Speight (2004), Hayes, Nakano, Muchmore et al. (2007) and Rosenstock, Capelleri, Bolinder, et al. (2004).

It was appropriately inferred from the results of the study that the PCP’s with greater years of practice experience had more positive attitude about their patients on the insulin initiation therapeutic process than those of lesser experience, and that the reason those who were of lesser experience disagreed more strongly was due to the impact of study conducted by Riddle (2002) being emphatically taught in medical schools to these physicians who could be classified as recent graduate.

According to Riddell (2002), there has been an underuse of insulin therapy  in North America  despite medical evidence that showed that patients were experiencing greater benefits that the threat posed by complications.

The conclusions about the attitudes of the physicians towards the initiation of insulin treatment of type 2 diabetic patients, then  based on the results obtained from the surveys  as well as the scientific evidence presented in the Literature Review were justified .

Ethically, however the views and attitudes of the North American Physicians, especially those with more than 15years practice experience should be questioned, in that they held on top their beliefs that patients that are provided with initiation therapy procedure will experience negative metabolic effects despite the presence of current scientific research data that suggest otherwise.

In Riddell (2002) study the researcher highlighted compelling evidence from separate studies done  by The United Kingdom Diabetes Study, The Diabetes, Insulin-Glucose and Myocardial Infarction organizations that confirm that insulin treatment  was not harmful to patients and was most likely to beneficial to them (Malmberg, 1997, UK Prospective Database, 1998).

The results of these studies should have positively impacted on the attitude of the North American Physicians with over 15 years with respect to how they treat and communicate to their weekly type 2 diabetes patients, yet it had no effect except on the more recent graduates. This should be sen as an indictment on the ethicality of these physicians who under the Hippocratic oaths, had sworn to preserve the lives of their patients using all the available means in terms of information, technology, technique and all other pertinent and current practices and facilities.

The researchers and Harris Interactive made no ethical provisions in the development and application of the survey with respect to physician’s commitment to use the most current medical information, technology, technique as well as other critical resources to help guide attitudinal behavior towards the insulin initiation therapy of type 2 diabetes patients. They were therefore guilty of not initially appealing to the possible hidden prejudice and traditional thinking of these older and more physicians who influencing practically the entire medical profession in one direction, and as such the study was ethically lacking in its preparation in this regard.

Reference

Bradley, C., Speight, J. (2004). Patient perceptions of diabetes therapy assessing quality of life Diabetes Metab Res Rev (2002) Vol,18  (Suppl. 3) pp. S 64-69

Brown, J.B., Nichols, G.H., Perry, A. (2004). The burden of treatment failure in type 2 diabetes Diabetes Care Vol.27 pp.1535-1540

Hayes, R.P., Nakano, M., Muchmore, D.  et al. (2007). Effects of standard training  (Self directed) versus intensive training for Lily /Alkernes human insulin inhalation powder delivery system on patient reported  outcomes and patient evaluation of the system Diabetes Technol Ther (2007) Vol. 29 pp. 89-98

Hayes, R.P., Fitzgerald, J.J., Jacobs, S.J. (2008). Primary Care Physicians beliefs about insulin initiation in patients with type 2 diabetes International Journal of Clinical Practice Vol.62  pp. 860-868

Malmberg, K., (1997). Prospective randomized study of intensive treatment on long term survival after acute Myocardial Infarction in patients with type diabetes mellitus Diabetes Mellitus Insulin Glucose Infarction Infusion in Acute Myocardial Infarction Study Group (DIGAMI)  BMJ 1997 Vol.3.4 pp.1512-1513

Nathan, D.M., Buse, Davidson, M.B., et al. (2006). Management of hypoglycemia in type 2 diabetes: A consensus algorithm for initiation and adjustment therapy: A consensus statement from American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care (2006) Vol.29 pp.1963-1972

Riddle, M.C., (2002). The underuse of insulin therapy in North American Diabetes Metab Res  Rev  (2002) Vol. 18 (Suppl.3) pp. S .42- 49

Rosenstock, J., Capelleri, J.C., Bolinder, B. (2004). Patient satisfaction and glycaemic control after 1 year with insulated insulin (Exubra) in patients with type 2 diabetes Diabetes Care Vol. 27 pp.1318-1323

UK Prospective Diabetes Study (UKPDS) (1998).  Group, Intensive blood glucose control with non-conventional treatment  and risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet 1998 Vol. 352 pp. 837-853