Phillipov and Phillips (1) suggest that our finding (2) that U.S. physicians were significantly more disposed to delay insulin therapy than were physicians in all other countries surveyed contradicted reports from other studies of the proportion of patients with type 2 diabetes taking insulin in the U.S., Australia, and some European countries. Phillipov and Phillips conclude that either our findings cannot be generalized or that attitudes are not the key determinant of prescribing behavior.

We thank Phillipov and Phillips for providing additional information regarding international differences in insulin-prescribing attitudes and behaviors. We agree that attitudes alone do not determine physician prescribing behavior. Also important is the level of perceived need for insulin. The relevance of the attitude identified in our study depends explicitly on the level of perceived need for insulin treatment (delay of insulin “until it is absolutely essential”). If the need is perceived as greater in the U.S. than in other countries, U.S. physicians might be more likely to prescribe insulin even if are they have a higher threshold for making that choice. The level of perceived need might itself be a function of attitudes or it could be a result of actual differences in need, e.g., higher BMI, worse glycemic control, patient unwillingness to change lifestyles, etc.

We believe that finding out how all of these factors combine to influence physicians’ insulin-prescribing behaviors would be a major contribution to the field. We hope that others will continue the study of this issue.

1
Phillipov G, Phillips PJ: Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study (Letter).
Diabetes Care
29
:
952
–953,
2006
2
Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, Landgraf R, Kleinebreil L, the International DAWN Advisory Panel: Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study.
Diabetes Care
28
:
2673
–2269,
2005

M.P. has served on an advisory board for and has received honoraria from Novo Nordisk and has received honoraria/consulting fees from MannKind. R.R.R. has served on advisory boards for and has received honoroaria and consulting fees from Novo Nordisk.