Insulin initiation in type 2 diabetes is commonly delayed beyond clinical need, particularly in primary care. This delay results in avoidable chronic hyperglycaemia and an increased risk of developing diabetes-related complications.
by Elizabeth Holmes-Truscott
To tackle health system and professional barriers to timely insulin therapy within primary care, Associate Professor John Furler  (University of Melbourne) and colleagues developed the Stepping Up model of care. This model includes: a brief educational session for GPs and practice nurses; reorientation of health professional roles, with as enhanced role for the practice nurse; and mentoring by a credentialed diabetes educator (CDE-RN).
In a 12-month two-arm cluster randomised controlled trial, A/Prof Furler and colleagues (including the ACBRD’s Prof Jane Speight and Dr Elizabeth Holmes-Truscott) tested the effectiveness of the Stepping Up model, compared to usual care, in relation to rates of insulin prescription and HbA1c (average blood glucose over the past 12 weeks). Across the state of Victoria, 74 practices and 266 people with type 2 diabetes (for whom insulin initiation was appropriate) took part in the study.
The study findings, published in The BMJ , demonstrated that the Stepping Up model of care is associated with a significantly higher proportion of insulin initiation within primary care and greater reduction in HbA1c at 12 months. These outcomes were achieved without serious adverse events, worsening in depressive symptoms or diabetes distress. This pragmatic model of care has important implications for the future organisation of primary care for people with type 2 diabetes.
In a recently published secondary paper from Stepping Up , Dr Elizabeth Holmes-Truscott and colleagues examined the psychosocial predictors of insulin initiation among trial participants. These analyses demonstrated that, after controlling for the successful intervention, 12-month insulin use was predicted by participant’s baseline level of ‘willingness’ to use insulin. Thus, in addition to interventions to improve timely prescription of insulin within primary care, strategies are needed to improve psychological receptiveness to insulin among people with type 2 diabetes.
Furler J, O’Neal D, Speight J, Manski-Nankervis JA, Gorelik A, Holmes-Truscott E, Ginnivan L, Young D, Best J, Patterson E, Liew D (2017) Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial . BMJ. 8;356:j783
Holmes-Truscott E, Furler J, Blackberry I, O’Neal DN, Speight J. Predictors of insulin uptake among adults with type 2 diabetes in the Stepping Up Study . Diabetes Research and Clinical Practice. Online first: http://dx.doi.org/10.1016/j.diabres.2017.01.002