Although delaying insulin therapy leads to a worsening progression of diabetes, research by Brigham and Women's Hospital has found 30% of type 2 diabetic patients don't begin insulin when it's initially recommended, with the average start time being two years later.
Dr Alexander Turchin, director of quality in diabetes in the division of endocrinology, diabetes and hypertension at BWH, who led the study, was inspired by his own practice as an endocrinologist treating diabetic patients. "Unfortunately this isn't uncommon, patients being reluctant to start insulin therapy when it's recommended," says Turchin. "Many clinicians have encountered this phenomenon, but until our study it was not known just how prevalent delays in insulin initiation are. As physicians, we need to make sure that these patients are making fully informed decisions and that we understand their perspective to ensure they are treated effectively."
To find this information, investigators designed a computer programme to analyse electronic physician notes of BWH patients from 2000 to 2014 to identify patients with type 2 diabetes who initially declined insulin therapy. Of the 3,295 patients included in the analysis, nearly one third declined a physician's advice to begin insulin at the time the recommendation was made. People who initially declined, but ultimately accepted the recommendation to start insulin, on average, started the insulin therapy more than two years later, during which time their blood glucose levels had increased further.
Diabetes is increasingly common in the US, with over 30m people affected. The high prevalence of decline of insulin therapy by patients that the study found suggests, per the researcher's estimations, that it could mean over 1m people in the US find themselves in this situation. The team notes further investigation is needed to determine the reasons, risk factors and long-term outcomes of these patients' important clinical decision.
Abstract
Aims: To design and validate a natural language processing algorithm to identify insulin therapy decline from the text of physician notes, and to determine the prevalence of insulin therapy decline and its impact on insulin initiation.
Methods: We designed the algorithm using the publicly available natural language processing platform Canary. We evaluated the accuracy of the algorithm on 1501 randomly selected primary care physicians’ notes from the electronic medical record system of a large academic medical centre. Using the validated language model, we then studied the prevalence of insulin therapy decline between 2000 and 2014.
Results: The algorithm identified documentation of insulin therapy decline with a sensitivity of 100% (95% CI 82.4–100), a positive predictive value of 95% (95% CI 74.4–99.9), and a specificity of 99.9% (95% CI 99.6–100.0). We identified 3295 insulin-naïve adults with Type 2 diabetes who were recommended insulin therapy; 984 of them (29.9%) initially declined insulin. People with HbA1c ≥ 75 mmol/mol (9.0%) were more likely [766/2239 (34.2%)] to have declined insulin than people with HbA1c 53–63 mmol/mol (7.0–7.9%) and 64–74 mmol/mol (8.0–8.9%; P < 0.0001). Among the people who initially declined but ultimately started insulin [374/984 (38.0%)], mean time to insulin initiation was 790 days.
Conclusions: Insulin therapy decline is common, potentially leading to progression of hyperglycaemia and a delay in achievement of glycaemic control. Further investigation is needed to determine the reasons, risk factors and long-term outcomes of this important clinical phenomenon.
Authors
N Hosomura, S Malmasi, D Timerman, VJ Lei, H Zhang, L Chang, A Turchin
[link url="https://www.sciencedaily.com/releases/2017/09/170914152335.htm"]Brigham and Women’s Hospital material[/link]
[link url="http://onlinelibrary.wiley.com/doi/10.1111/dme.13454/abstract;jsessionid=12653DD8268177979591E2BA2BAB710B.f02t03"]Diabetic Medicine abstract[/link]