Barriers to ınsulin treatment ınitiation of family physicians, a qualitative study

Introduction and Aim: It is estimated that 537 million people have diabetes in 2021 and this number is estimated to reach 643 million in 2030 and 783 million in 2045. Recognizing the strategic role of primary care in the diagnosis and treatment of type 2 diabetes, the American Diabetes Association (ADA) has published annual guidelines for diabetes management tailored specifically to primary care. Appropriate treatment requires the cooperation of the primary care physician, the patient himself, and the diabetes specialist. The aim of this study is to question family physicians' barriers to starting insulin in primary care through individual interviews and to make primary care more active about diabetes and insulin management, which has a very important place in primary care, and to offer solutions for problems in the light of the results. Method: This research was designed in a qualitative design. The study group consisted of family physicians who have been actively working in primary ort he at least 1 year in Trabzon. In-depth semi-structured individual interviews were conducted between January 15 and March 2023. The questionnaire form was prepared by the researchers. Interviews were conducted until the data reached saturation. The interviews were audio recorded so that they could be transcribed without errors. Discussion and Results: ort he purpose of the study, a total of 16 physicians, including 3 general practitioners, 1 public health specialist working as a family physician, 4 contracted family medicine specialist training (SAHU) and 8 family medicine specialists, were interviewed. In all our interviews, it was learned that our physicians did not start insulin for their patients in primary care, and only prescribed insulin to pregnant women whom a family medicine specialist thought could adapt to the treatment. Some of our doctors did not know which insulins were covered by the reimbursement. Physicians, who knew which insulins family physicians could prescribe for reimbursement, said that they did not want to use these insulins and directed them to a higher level when the patient needed insulin. Three main themes emerged in our qualitative research: 1- "Patient's Perception of Diabetes Management", 2- "Physician's Perception of Diabetes Management" and 3- "Structure of the Health System". In a study conducted abroad; Despite the availability of a wide variety of new therapies, as outlined in the ADA/EASD and NICE guidelines, clinical inertia in initiating insulin and intensifying therapy in diabetes is a chronic problem globally. In a quantitative multicenter cross-sectional study investigating the insulin initiation barriers of family physicians in our country, it was determined that the insulin initiation status of primary care physicians was insufficient and that insulin initiation barriers were caused by physicians, patients, and the system. These results are similar to our study. As a result, family physicians in primary care in our country do not prescribe many oral antidiabetic drugs to their patients besides insulin. This shows that the primary care, which has a very important place in chronic patient management, cannot fulfill this function, and this situation leads to a serious economic burden. Regular education of primary care physicians about diabetes management and insulin, providing training to patients on diabetes self-management, prescribing analogue insulins within the scope of reimbursement in primary care, and the arrival of the referral chain to fulfill the door-keeper function of family medicine can be steps towards solving the problems. If the patient manages his chronic diseases with a primary care physician who is more easily accessible and equipped with sufficient knowledge and experience, the development of complications can be postponed and the risk of death and disability due to diabetes can be reduced throughout the country. Key Words: Primary care, family medicine, insülin, diabetes management