Background. The increasing use of basal insulin to improve glycemic control among adults with type 2 diabetes (T2D) has revealed a troubling problem: between one-quarter and one-third of patients who meet guidelines to initiate basal insulin refuse to do so. This phenomenon has been called “psychological insulin resistance” or PIR. Numerous studies have documented the major reasons why these patients are very reluctant to begin insulin (e.g., injection anxiety, concerns about hypoglycemia), but there is little information about how to help such patients actually begin insulin use. One approach to developing practical interventions to shorten or eliminate the time interval between recommendation and insulin initiation is to document the major reasons why initially reluctant patients eventually decide to begin insulin use. Identification of the events and processes involved will enable clinicians to focus on these factors early on to facilitate a speedier and less onerous transition to insulin use. 

Aims. In a large-scale, seven-country study of approximately 1000 adults with T2D, we identified some of the major reasons why patients with PIR eventually decided to begin using basal insulin regularly. In this study-- called EMOTION (AccEpting Insulin TreatMent for Reluctant PeOple with Type 2 DIabetes Mellitus – A GlObal Study to IdeNtify Effective Strategies)-- we report on differences in the reported reasons across the seven countries as well as differences based on patient characteristics (e.g., age, gender, time since diagnosis, and past use of injectables). Our goal in this study is to document the variability in reasons for eventually initiating insulin in PIR patients based on health care context, and cultural, demographic and disease differences. In combination, the results will enable clinicians to focus on which patients may be at high risk for PIR and to address the most likely factors that will facilitate initiation.

Methods. We used patient panels, relevant website announcements and referrals from local clinicians to identify and recruit 150 patients from each of seven countries: Brazil, Canada, Germany, Japan, Spain, UK, and US. Inclusion criteria were: age ≥21 years old, initiated basal insulin within the past 24 months, had T2D for ≥12 months before basal insulin initiation, indicated being reluctant to begin insulin therapy when it was first recommended, but now currently using insulin. Patients then completed a 30-minute online survey battery that included a newly designed questionnaire (the PIR Solutions Questionnaire, or PSQ) to identify patient-reported events that successfully addressed their PIR and convinced them to begin basal insulin. PSQ items were developed from comprehensive interviews with 29 patients and 29 clinicians in six of the seven countries, resulting in a total of 45 items. Also included in the battery were items that examined patient demographics, past medication experiences, early attitudes regarding insulin, and characteristics of their health care system.   

Results. Survey data from approximately 1000 respondents will be presented, focusing on the use of multiple regression analyses to identify country and patient factors that account for variations in the most frequently endorsed items/reasons for PIR success. These analyses will address unique patient and country factors that account for differences among patients in each country in reasons for eventually initiating insulin. 

Discussion. These findings will identify the unique country and patient factors that contribute to the successful initiation and maintenance of basal insulin among individual patients with PIR so that more patient-specific strategies to enhance insulin initiation can be developed.

Identifying solutions to psychological insulin resistance: key differences observed across seven countries