Diabetes is a common, morbid and expensive disease among veterans. Achieving adequate glycemic control can reduce the devastating complications of diabetes. Unfortunately a large percentage of veterans with type 2 diabetes continue to have poorly controlled blood sugars. Insulin is the most potent medication for improving glycemic control, but is not used often enough due to barriers that are both patient and provider driven.
The objectives of this study were to (a) determine if psychological barriers to insulin initiation in patients with uncontrolled type 2 diabetes are favorably affected by a group insulin education and insulin initiation visit; (b) evaluate the feasibility of the intervention as measured by the percent of patients who are referred to the class, but either cancel without rescheduling or fail to report and the percent of patients who begin insulin; and (c) evaluate the safety of the intervention as measured by the proportion of patients experiencing hypoglycemic symptoms; proportion of patients requiring sugar intake to manage hypoglycemia; and the proportion of patients requiring assistance to manage hypoglycemia.
This was a pre-post pilot study of a group intervention. Subjects were eligible to participate if they (a) were referred to the group by their primary care provider; (b) had uncontrolled diabetes (hemoglobin A1c (A1c) >= 8.0%) not treated with insulin; (c) brought a glucose log to the first visit and (d) signed a consent form. Subjects attended two group visits, two weeks apart, during which they received education regarding goals of therapy, insulin use, and hypoglycemia. Insulin was initiated if appropriate and accepted by the subject. The Barriers to Insulin Treatment Questionnaire (BIT) was completed at each visit. The BIT is a 14 item self-administered questionnaire with 5 subscales, each representing a different psychological barrier to insulin treatment. It is scored 1-10 where 10 represents major barriers to insulin treatment. The change in BIT score from baseline was assessed by paired t-test.
From April to July 2008, 102 patients were referred to the insulin clinic, and 71 (70%) reported to the first visit. Thirty-nine were eligible for the study. Thirty-two subjects completed the study; 25 (78%) of these started insulin. Mean age was 65, and mean pre-study A1c was 9.5%. The total BIT score was significantly improved from a mean of 4.27 to 3.51 (p=0.007). Improvement in each subscale score was also observed, although only one ("stigmatization by insulin injections") reached statistical significance (p=0.02). Ten subjects (31%) reported symptoms of low blood sugar and had at least one recorded value less than 70. Eight of these had started insulin. None experienced a severe hypoglycemic event.
Psychological barriers to insulin initiation are reduced with a group insulin education and initiation visit. A larger, randomized study should compare this approach to traditional insulin initiation and determine its effect on diabetes control.
External Links for this Project
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