Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners
Open accessAbstract
Background: Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines. Methods: Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence. Results: Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified. Conclusions: The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
This finding may also reflect medication management challenges including nonadherence related to cost, storage, or dosing complexity.
“This finding may also reflect medication management challenges including nonadherence related to cost, storage, or dosing complexity [83–85].”
From Machine learning-driven risk prediction for post-hospitalization diabetes case management: Integrating clinical and social determinants of health (2026) · cites this paper as [83]
The Results section (no page supplied) describes patients who cannot resuspend NPH insulin or use certain devices, supporting a medication-management difficulty. But the paper studies practitioners’ non-adherence to prescribing guidelines, not patients’ medication nonadherence; its discussion of higher costs concerns insulin selection, and the cited passages do not link nonadherence to storage or dosing complexity. (LLM, conf=0.81)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Qualitative research. Introducing focus groups.
Kitzinger, J. (1995) · BMJ · doi:10.1136/bmj.311.7000.299 · Cited by 6,939 · see citing works
Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement
Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P.-A. C., & Rubin, H. R. (1999) · JAMA · doi:10.1001/jama.282.15.1458 · Cited by 6,677 · see citing works
Davies, M. J., D’Alessio, D. A., Fradkin, J., Kernan, W. N., Mathieu, C., Mingrone, G., Rossing, P., Tsapas, A., Wexler, D. J., & Buse, J. B. (2018) · Diabetes Care · doi:10.2337/dci18-0033 · Cited by 3,518 · see citing works
Comparing focus groups and individual interviews: findings from a randomized study
Guest, G., Namey, E., Taylor, J., Eley, N. T., & McKenna, K. (2017) · International Journal of Social Research Methodology · doi:10.1080/13645579.2017.1281601 · Cited by 638 · see citing works
Effects of evidence-based clinical practice guidelines on quality of care: a systematic review
Lugtenberg, M., Burgers, J. S., & Westert, G. P. (2009) · BMJ Quality & Safety · doi:10.1136/qshc.2008.028043 · Cited by 479 · see citing works
Lugtenberg, M., Schaick, J. M. Z.-V., Westert, G. P., & Burgers, J. S. (2009) · Implementation Science · doi:10.1186/1748-5908-4-54 · Cited by 479 · see citing works
Maier, C. B., & Aiken, L. H. (2016) · European Journal of Public Health · doi:10.1093/eurpub/ckw098 · Cited by 383 · see citing works
Perceived barriers to guideline adherence: A survey among general practitioners
Lugtenberg, M., Burgers, J., Besters, C. F., Han, D., & Westert, G. (2011) · BMC Family Practice · doi:10.1186/1471-2296-12-98 · Cited by 253 · see citing works
Why are clinical practice guidelines not followed?
Barth, J. H., Misra, S., Aakre, K. M., Langlois, M. R., Watine, J., Twomey, P. J., & Oosterhuis, W. P. (2015) · Clinical Chemistry and Laboratory Medicine (CCLM) · doi:10.1515/cclm-2015-0871 · Cited by 222 · see citing works
Factors affecting the uptake of new medicines: a systematic literature review
Lublóy, Á. (2014) · BMC Health Services Research · doi:10.1186/1472-6963-14-469 · Cited by 211 · see citing works
Nurse prescribing of medicines in 13 European countries
Maier, C. B. (2019) · Human Resources for Health · doi:10.1186/s12960-019-0429-6 · Cited by 179 · see citing works
NHG-Standaard Diabetes mellitus type 2
Rutten, G. E. H. M., de Grauw, W. J. C., Nijpels, G., Goudswaard, A. N., Uitewaal, P. J. M., Does, F. E. E. V. D., Heine, R. J., van Ballegooie, E., Verduijn, M., & Bouma, M. (2009) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-313-6614-9_8 · Cited by 150 · see citing works
Reasons for intentional guideline non-adherence: A systematic review
Arts, D. L., Voncken, A. G., Medlock, S. K., Abu–Hanna, A., & van Weert, H. C. P. M. (2016) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2016.02.009 · Cited by 146 · see citing works
Houweling, S. T., Kleefstra, N., van Hateren, K. J., Groenier, K. H., Jong, B. M., & Bilo, H. J. G. (2011) · Journal of Clinical Nursing · doi:10.1111/j.1365-2702.2010.03562.x · Cited by 94 · see citing works
The contribution of Physician Assistants in primary care: a systematic review
Halter, M., Drennan, V. M., Chattopadhyay, K., Carneiro, W., Yiallouros, J., de Lusignan, S., Gage, H., Gabe, J., & Grant, R. (2013) · BMC Health Services Research · doi:10.1186/1472-6963-13-223 · Cited by 82 · see citing works
Use and Out-of-Pocket Costs of Insulin for Type 2 Diabetes Mellitus From 2000 Through 2010
Lipska, K. J., Ross, J. S., Houten, H. K. V., Beran, D., Yudkin, J. S., & Shah, N. D. (2014) · JAMA · doi:10.1001/jama.2014.6316 · Cited by 79 · see citing works
New medicines in primary care: a review of influences on general practitioner prescribing
Mason, A. (2008) · Journal of Clinical Pharmacy and Therapeutics · doi:10.1111/j.1365-2710.2008.00875.x · Cited by 77 · see citing works
Gross, R., Tabenkin, H., Porath, A., Heymann, A., Greenstein, M., Porter, B., & Matzliach, R. (2003) · Family Practice · doi:10.1093/fampra/cmg512 · Cited by 59 · see citing works
Trends in antidiabetic drug utilization and expenditure in Denmark: A 22‐year nationwide study
Bang, C., Mortensen, M. B., Lauridsen, K. G., & Bruun, J. M. (2019) · Diabetes Obesity and Metabolism · doi:10.1111/dom.13877 · Cited by 54 · see citing works
Adoption of new drugs by physicians: a survival analysis
Garjón, F. J., Azparren, A., Vergara, I., Azaola, B., & Loayssa, J. R. (2012) · BMC Health Services Research · doi:10.1186/1472-6963-12-56 · Cited by 50 · see citing works
Resolving the Tension Between Population Health and Individual Health Care
Sox, H. C. (2013) · JAMA · doi:10.1001/jama.2013.281998 · Cited by 49 · see citing works
National trends in prescription drug expenditures and projections for 2019
Schumock, G. T., Stubbings, J., Hoffman, J. M., Wiest, M. D., Suda, K. J., Rim, M. H., Tadrous, M., Tichy, E. M., Cuéllar, S., Clark, J. S., et al. (2019) · American Journal of Health-System Pharmacy · doi:10.1093/ajhp/zxz109 · Cited by 37 · see citing works
Adherence to Guidelines for Community-Acquired Pneumonia
Brown, P. D. (2004) · PharmacoEconomics · doi:10.2165/00019053-200422070-00001 · Cited by 34 · see citing works
Sarkar, S., Heyward, J., Alexander, G. C., & Kalyani, R. R. (2021) · JAMA Network Open · doi:10.1001/jamanetworkopen.2021.28782 · Cited by 29 · see citing works
Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands
van Avendonk, M. J. P., Gorter, K. J., van den Donk, M., & Rutten, G. E. H. M. (2008) · Primary care diabetes · doi:10.1016/j.pcd.2008.10.007 · Cited by 25 · see citing works
Variation in formulary adherence in general practice over time (2003-2007)
van Dijk, L., de Jong, J. D., Westert, G. P., & de Bakker, D. H. (2011) · Family Practice · doi:10.1093/fampra/cmr043 · Cited by 19 · see citing works
Analysis of Trends in Insulin Utilization and Spending Across Canada From 2010 to 2015
Xu, Y., Gomes, T., Mamdani, M., Juurlink, D. N., Cadarette, S. M., & Tadrous, M. (2018) · Canadian Journal of Diabetes · doi:10.1016/j.jcjd.2018.08.190 · Cited by 14 · see citing works
van Schoonhoven, A. V., Gout-Zwart, J. J., de Vries, M. J. S., van Asselt, A. D. I., Dvortsin, E., Vemer, P., van Boven, J. F. M., & Postma, M. J. (2019) · PLoS ONE · doi:10.1371/journal.pone.0221856 · Cited by 14 · see citing works
Patient Care and Population Health: Goals, Roles and Costs
Kaldjian, L. C. (2014) · Journal of Public Health Research · doi:10.4081/jphr.2014.311 · Cited by 12 · see citing works
Ikeda, S., Crawford, B., & Sato, M. (2015) · BMC Health Services Research · doi:10.1186/s12913-016-1264-2 · Cited by 11 · see citing works
Brismar, K., Benroubi, M., Nicolay, C., Schmitt, H., Giaconia, J. M., & Reaney, M. D. (2013) · Journal of Medical Economics · doi:10.3111/13696998.2013.812040 · Cited by 8 · see citing works
Heymann, A. D., Kritz, V., Hemo, B., Kertes, J., & Becker, M. (2013) · Primary care diabetes · doi:10.1016/j.pcd.2012.12.005 · Cited by 7 · see citing works
Dankers, M., Hek, K., Nelissen-Vrancken, M. H. J. M. G., Houweling, S. T., Mantel-Teeuwisse, A. K., & van Dijk, L. (2022) · British Journal of General Practice · doi:10.3399/bjgp.2021.0581 · Cited by 7 · see citing works
Self-citationPrescription of Insulin Glargine in Primary Care Practices in Germany
Rathmann, W., Haastert, B., Riebel, P., Schröder-Bernhardi, D., Kostev, K., Huppertz, E., & Giani, G. (2007) · Experimental and Clinical Endocrinology & Diabetes · doi:10.1055/s-2007-972562 · Cited by 6 · see citing works
The use of evidence during group meetings of Dutch general practitioners
ter Brugge, B. P. H., Bartelink, M.-L. E. L., Damoiseaux, R. A. M. J., & GROOT, E. D. (2017) · Education for Primary Care · doi:10.1080/14739879.2017.1344934 · Cited by 5 · see citing works
Zhang, H., Barner, J. C., Moczygemba, L. R., & Rascati, K. L. (2020) · Journal of Managed Care & Specialty Pharmacy · doi:10.18553/jmcp.2020.26.11.1434 · Cited by 4 · see citing works
Are newer insulins always the better option?
Malkani, S. (2019) · Current Opinion in Endocrinology Diabetes and Obesity · doi:10.1097/med.0000000000000469 · Cited by 2 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- [12]National Institute for Health and Care Excellence (NICE) Type 2 diabetes in adults: management Clinical Guideline 2015 London NICE 26741015
Cited by
Sorted by citations
Morales, J., Dagogo-Jack, S. E., Fonseca, V. A., Neumiller, J. J., & Rosas, S. E. (2023) · Clinical Diabetes · doi:10.2337/cd22-0110 · Cited by 21 · see citing works
Kurevija, T., Šojat, D., Bosnić, Z., Mujaj, B., Canecki-Varžić, S., & Majnarić, L. T. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13061617 · Cited by 8 · see citing works
Marketing of medicines in primary care: An analysis of direct marketing mailings and advertisements
Dankers, M., Verlegh, P. W. J., Weber, K., Nelissen-Vrancken, M. H. J. M. G., van Dijk, L., & Mantel-Teeuwisse, A. K. (2023) · PLoS ONE · doi:10.1371/journal.pone.0290603 · Cited by 4 · see citing works
Self-citationHek, K., Saïd, F. L., Korevaar, J. C., Flinterman, L. E., van Dijk, L., & van den Bemt, P. M. L. A. (2022) · BMC Family Practice · doi:10.1186/s12875-022-01911-8 · Cited by 1 · see citing works
Lee, S.-Y., Saleem, M., Land, A. M., DeLaney, E. W., Garretson, A. R., Patel, M., Hall, A. G., Westrick, S., Ovalle, F., Cherrington, A. L., et al. (2026) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2026.106604
Rahimi, M., Farshadfar, S., Soheyli, A., Mohamadi, M., & Haseli, A. (2025) · Journal of Comprehensive Pediatrics · doi:10.5812/jcp-158830
- Authors
- Dankers, M., van den Berk-Bulsink, M. J. E., van Dalfsen-Slingerland, M., Nelissen-Vrancken, H. J. M. G., Mantel-Teeuwisse, A. K., & van Dijk, L.
- Affiliations
- University of Groningen (NL)
- Instituut voor Verantwoord Medicijngebruik (NL)
- Utrecht University (NL)
- Corresponding author
- Dankers, M.
- Venue
- BMC Primary Care
- Published
- 2022-06-13
- Volume
- 23
- Issue
- 1
- Pages
- 150-150
- ISSN
- 1471-2296 (ISSN-L)
- 2731-4553
- PMC
- PMC9189803
- OpenAlex
- W4282596410
- Cited by
- 7
- References
- 37
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 1 · 2023: 2 · 2022: 1
- FWCI
- 1.32
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Family Practice (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- Funders
- Ministerie van Volksgezondheid, Welzijn en Sport
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Keywords
- guideline adherence, insulin prescribing, type 2 diabetes, NPH insulin, primary care physicians, knowledge and attitudes, barriers to prescribing, pharmaceutical marketing, interprofessional agreement
- MeSH terms
- Diabetes Mellitus, Type 2, Humans, Primary Health Care, Qualitative Research, General Practitioners, Insulins
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
