Factors that drive insulin-dosing decisions of diabetes care providers: a vignette-based study in the Netherlands

Aim To test how certain patient factors would influence the decision of Dutch care providers regarding insulin dose adjustments. We hypothesize that some of these decisions would diverge from recent evidence and consensus statements. Methods We developed narrative vignettes describing clinical scenarios of patients receiving basal insulin therapy. For each vignette, the respondents were asked to indicate whether they would advise a change in insulin dose. A total of 520 paper questionnaires were distributed among physicians and nurses in primary and secondary care in the Netherlands. Multivariate linear and logistic regression analyses were performed to identify factors associated with dosing decisions. Results A total of 190 (37%) questionnaires were returned. In cases of a severe rather than mild hypoglycaemic event, care providers were nearly five times more likely to decrease the dose (odds ratio 4.77, 95% CI 1.65–13.75). Care providers were six times more likely to increase the dose when the patient's current dose was low (30 units) rather than high (90 units) (odds ratio 6.38, 95% CI 3.04–13.37). The plasma glucose concentration during a hypoglycaemic event and a known history of cardiovascular disease did not influence the care providers' dosing decisions. Conclusion Evidence regarding the optimum insulin titration is not always translated into clinical practice. When formulating guidelines, misconceptions should be identified and addressed. What's new? Many guidelines and consensus statements have been developed to advise care providers on the implementation of insulin therapy in people with Type 2 diabetes, but little is known about the actual strategies that are followed by care providers in clinical practice. Some of the decisions of care providers regarding insulin dose adjustments diverge from the available evidence and consensus statements. This study showed that pseudo‐hypoglycaemic events and high insulin doses are perceived as barriers to intensifying insulin dose. Based on our results, we recommend that misconceptions should be specifically identified and addressed when formulating and implementing guidelines.