Clinical inertia to initiation of insulin therapy among patients with type two diabetes in Moi Teaching and Referral Hospital, Eldoret Kenya

Abstract

Background: The prevalence of diabetes among the Kenyan adult population is 3%, with Type 2 Diabetes (T2DM) contributing to over 90% of all cases. Despite insulin being a major component in T2DM management, it is not used enough partly due to a phenomenon known as clinical inertia (CI). In diabetology, CI is defined as failure to escalate antidiabetic treatment despite failing to achieve glycemic targets. It has been shown to be a significant contributor to poor glycemic control but has yet to be explored in Kenya. This study defined CI as failure to use exogenous insulin as part of antidiabetic management for patients with T2DM and glycated hemoglobin (HbA1c) levels of 9% or more despite being on oral hypoglycemic agents (OHAs) and regular clinic follow-up for at least 3 months. Objectives: The broad objective was to determine the prevalence of CI among patients with T2DM at Moi Teaching and Referral Hospital (MTRH) Diabetes out Patient Clinic (DOPC). Specific objectives were to: identify associations between CI and patient factors (demographic and clinical characteristics, clinical depression, attitudes towards insulin therapy, level of DM self-care literacy) and to explore factors contributing to CI as considered by clinicians working at DOPC. Methods: This was a mixed methods study. Quantitative study: a total of 480 patients were recruited into the study. Interviewer administered patient questionnaires were used to record patients biodata, HbA1c levels, attitudes towards insulin as assessed by the Insulin Treatment Appraisal Scale (ITAS), presence of clinical depression indicated by PHQ-9 scores, and levels of diabetes self-care knowledge indicated by Spoken Knowledge in Low Literacy in Diabetes (SKILLD) scores. Statistical analysis was done using R software at 95% confidence and p value 0.05. Chi squares were used to determine significance of associations while Odds Ratios (ORs) and multiple linear regression were used to interconnect dependent and independent variables. Qualitative study: 15 clinicians were recruited using purposive sampling. Phenomenology was employed with key informant interviews used to collect data. Data were analyzed by thematic content using Nvivo version 12. Results: Out of 480 patients, 259 had HbA1C levels of 9% or more and the prevalence of CI was 54%. Majority of the patients were female (61%) and were married (71%) Single marital status seemed to increase risk of CI (OR 2.1; p value 0.047) while male gender seemed to be protective (OR 0.65; p value 0.041). No associations were found between CI and clinical depression, patients’ attitudes towards insulin therapy or level of DM self-care literacy. Clinicians believed insulin was important in T2DM management but withheld prescribing it due to their knowledge gaps on insulin prescription, workplace resource constraints, perceived patient resistance to insulin therapy and perceived negative impact of insulin on patient quality of life. Conclusion: The prevalence of CI was high in MTRH. Single marital status increased the risk of CI while male gender was protective. Clinician factors were found to be the key drivers of CI. Recommendation: There is need to address the negative attitudes towards insulin therapy among clinicians at the DOPC with an aim of reducing CI. Prospective implementation research as a follow-up to this study will assess the effectiveness of various existing strategies targeted to reduce CI.