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Hollander PA, Krause-Steinrauf H, Butera NM, Kazemi EJ, Ahmann AJ, Fattaleh BN, Johnson ML, Killean T, Lagari VS, Larkin ME, Legowski EA, Rasouli N, Willis HJ, Martin CL. The Use of Rescue Insulin in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2024; 47:638-645. [PMID: 37756542 PMCID: PMC10973913 DOI: 10.2337/dc23-0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE To describe rescue insulin use and associated factors in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). RESEARCH DESIGN AND METHODS GRADE participants (type 2 diabetes duration <10 years, baseline A1C 6.8%-8.5% on metformin monotherapy, N = 5,047) were randomly assigned to insulin glargine U-100, glimepiride, liraglutide, or sitagliptin and followed quarterly for a mean of 5 years. Rescue insulin (glargine or aspart) was to be started within 6 weeks of A1C >7.5%, confirmed. Reasons for delaying rescue insulin were reported by staff-completed survey. RESULTS Nearly one-half of GRADE participants (N = 2,387 [47.3%]) met the threshold for rescue insulin. Among participants assigned to glimepiride, liraglutide, or sitagliptin, rescue glargine was added by 69% (39% within 6 weeks). Rescue aspart was added by 44% of glargine-assigned participants (19% within 6 weeks) and by 30% of non-glargine-assigned participants (14% within 6 weeks). Higher A1C values were associated with adding rescue insulin. Intention to change health behaviors (diet/lifestyle, adherence to current treatment) and not wanting to take insulin were among the most common reasons reported for not adding rescue insulin within 6 weeks. CONCLUSIONS Proportionately, rescue glargine, when required, was more often used than rescue aspart, and higher A1C values were associated with greater rescue insulin use. Wanting to use noninsulin strategies to improve glycemia was commonly reported, although multiple factors likely contributed to not using rescue insulin. These findings highlight the persistent challenge of intensifying type 2 diabetes treatment with insulin, even in a clinical trial.
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Affiliation(s)
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Nicole M. Butera
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Erin J. Kazemi
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | | | | | - Mary L. Johnson
- International Diabetes Center at Park Nicollet, Minneapolis, MN
| | - Tina Killean
- Southwestern American Indian Center, Phoenix, AZ
| | | | | | - Elizabeth A. Legowski
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Neda Rasouli
- University of Colorado, School of Medicine, and VA Eastern Colorado Health Care System, Aurora, CO
| | - Holly J. Willis
- International Diabetes Center at Park Nicollet, Minneapolis, MN
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Okazaki K, Takahashi N, Shingaki T, Perez-Nieves M, Stuckey H. Key factors for overcoming psychological insulin resistance: A qualitative study in Japanese people with type 2 diabetes. Prim Care Diabetes 2022; 16:411-416. [PMID: 35256314 DOI: 10.1016/j.pcd.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022]
Abstract
AIMS We report the key factors that motivate reluctant Japanese people with type 2 diabetes (T2D) to initiate insulin treatment. METHODS Participants were asked questions pertaining to 2 primary areas of exploration in a concurrent mixed methods approach: (a) understanding people's thoughts and perceptions before and after insulin initiation and any related factors; and (b) exploring the reasons behind people's responses. Data were analyzed using Steps for Coding and Theorization. RESULTS Participant responses broadly related to 3 themes which influence insulin initiation; 1. Advice from a health care provider (HCP) that insulin is an appropriate treatment; 2. Demonstration by HCPs on how to use the insulin pen/needle and the injection process; and 3. Resignation/surrender/acceptance of insulin, where participants felt there was no other choice but to commence insulin. CONCLUSIONS Based on the 3 identified themes, it is important for HCPs to explain the benefits of insulin and demonstrate and explain the injection procedure to reluctant Japanese people with T2D. We also identified resignation/surrender/acceptance of insulin as a reason for treatment commencement. This study provides important information to assist HCPs in helping reluctant Japanese people with T2D to initiate basal insulin therapy.
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Affiliation(s)
- Kentaro Okazaki
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan.
| | - Noriyuki Takahashi
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan.
| | - Tomotaka Shingaki
- Eli Lilly Japan K.K., 5-1-28 Isogami-dori, Chuo-ku Kobe, Hyogo 651-0086, Japan.
| | - Magaly Perez-Nieves
- Eli Lilly and Company, Global Headquarters Lilly Corporate Center, Indianapolis, IN 46285, USA.
| | - Heather Stuckey
- Pennsylvania State University, College of Medicine, 201 Old Main, University Park, PA 16802, USA.
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Holmes-Truscott E, Holloway EE, Husin HM, Furler J, Hagger V, Skinner TC, Speight J. 'Is insulin right for me?': Feasibility of a pilot randomised controlled trial and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes. Diabet Med 2022; 39:e14759. [PMID: 34865232 DOI: 10.1111/dme.14759] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022]
Abstract
AIMS Acceptable and accessible interventions are needed to address 'psychological insulin resistance', which is a common barrier to insulin uptake among adults with type 2 diabetes (T2D). Our aim was to test the feasibility of a randomised controlled trial (RCT) study design and acceptability of a theoretically grounded, psycho-educational, web-based resource to reduce negative insulin appraisals among adults with T2D. METHODS A double-blinded, parallel group, two-arm pilot RCT (1:1), comparing intervention with active control (existing online information about insulin). Eligible participants were Australian adults with T2D, taking oral diabetes medications. EXCLUSION CRITERIA prior use of injectable medicines; being 'very willing' to commence insulin. Primary outcomes: study feasibility (recruitment ease, protocol fulfilment, attrition, data completeness); secondary outcomes: intervention acceptability (intervention engagement, user feedback) and likely efficacy (negative Insulin Treatment Appraisal Scale [ITAS] scores at follow-up). Online surveys completed at baseline and 2 weeks. RESULTS During 4-week recruitment, 76 people expressed interest: 51 eligible and 35 enrolled (intervention = 17, control = 18; median[interquartile range] age = 62[53, 69] years; 17 women). Protocol fulfilment achieved by 26 (74%) participants (n = 13 per arm), with low participant attrition (n = 6, 17%). Intervention acceptability was high (>80% endorsement, except format preference = 60%). ITAS negative scores differed between-groups at follow-up (M diff = -6.5, 95% confidence interval: -10.7 to -2.4), favouring the intervention. CONCLUSIONS This novel web-based resource ("Is insulin right for me?") is acceptable and associated with a likely reduction in negative insulin appraisals, relative to existing resources. This pilot shows the study design is feasible and supports conduct of a fully powered RCT.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Edith E Holloway
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Hanafi M Husin
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - John Furler
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Virginia Hagger
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Timothy C Skinner
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
- La Trobe Rural Health School, La Trobe University, Flora Hill, Victoria, Australia
- Department of Psychology, University of Copenhagen, København, Denmark
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
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Holmes-Truscott E, Holloway EE, Husin HM, Furler J, Hagger V, Skinner TC, Speight J. Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of ' Is insulin right for me?'. BMJ Open 2022; 12:e051524. [PMID: 35190420 PMCID: PMC8862461 DOI: 10.1136/bmjopen-2021-051524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'. METHODS AND ANALYSIS Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000). EXCLUSION CRITERIA experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up. SECONDARY OUTCOMES between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle. ETHICS AND DISSEMINATION Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary. TRIAL REGISTRATION NUMBER ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Edith E Holloway
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Hanafi M Husin
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - John Furler
- Department of General Practice, University of Melbourne, Carlton, Victoria, Australia
| | - Virginia Hagger
- School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia
| | - Timothy C Skinner
- Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Department of Psychology, University of Copenhagen, Kobenhavn, Denmark
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
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Holloway EE, Speight J, Furler J, Hagger V, O'Neal DN, Skinner TC, Holmes-Truscott E. 'Is Insulin Right for Me?' Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy in type 2 diabetes. BMJ Open 2021; 11:e045853. [PMID: 34561252 PMCID: PMC8475140 DOI: 10.1136/bmjopen-2020-045853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To develop a theory and evidence-based web intervention to reduce psychological barriers towards insulin therapy among adults with non-insulin-treated type 2 diabetes (T2D). METHODS Salient psychological barriers towards insulin were identified from the literature and classified using the Theoretical Domains Framework (TDF). Relevant TDF domains were mapped to evidence-based behaviour change techniques (BCTs), which informed the content for each barrier. Acceptability was explored using cognitive debriefing interviews (n=6 adults with T2D). RESULTS 'Is Insulin Right for Me' addresses eight barriers, phrased as common questions: Does insulin mean my diabetes is more serious? Do insulin injections cause complications? Is it my fault I need to inject insulin? Will I gain weight? Will injecting hurt? What about hypos? Will injecting insulin be a burden? What will others think of me? BCTs, including persuasive communication and modelling/demonstration, were delivered using appropriate methods (eg, demonstration of the injection process). Participant suggestions for improvement included clear and direct messages, normalising insulin and avoiding confronting images. CONCLUSIONS 'Is Insulin Right for Me' is the first theory and evidence-based, web intervention designed to reduce psychological barriers towards insulin therapy for adults with T2D. Evaluation is needed to determine its impact on negative appraisals and receptiveness towards insulin.
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Affiliation(s)
- Edith E Holloway
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - John Furler
- Department of General Practice, The University of Melbourne, Carlton, Victoria, Australia
| | - Virginia Hagger
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - David N O'Neal
- Department of General Practice, The University of Melbourne, Carlton, Victoria, Australia
| | - Timothy C Skinner
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Department of Psychology, University of Copenhagen, Kobenhavn, Denmark
| | - Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
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Forst T, Choudhary P, Schneider D, Linetzky B, Pozzilli P. A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes. Diabetes Metab Res Rev 2021; 37:e3418. [PMID: 33098260 PMCID: PMC8519070 DOI: 10.1002/dmrr.3418] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/17/2020] [Accepted: 08/09/2020] [Indexed: 12/18/2022]
Abstract
Initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus (T2DM). Despite increasing choices in pharmacological approaches, intensified glucose monitoring and improvements in quality of care, many patients do not achieve the desired level of glycaemic control. Although insulin therapy, when optimized, can help patients reach their glycaemic goals, there are barriers to treatment initiation on both the side of the patient and provider. Providers experience barriers based on their perceptions of patients' capabilities and concerns. They may lack the confidence to solve the practical problems of insulin therapy and avoid decisions they perceive as risky for their patients. In this study, we review recommendations for basal insulin initiation, focussing on glycaemic targets, titration, monitoring, and combination therapy with non-insulin anti-hyperglycaemic medications. We provide practical advice on how to address some of the key problems encountered in everyday clinical practice and give recommendations where there are gaps in knowledge or guidelines. We also discuss common challenges faced by people with T2DM, such as weight gain and hypoglycaemia, and how providers can address and overcome them.
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Affiliation(s)
- Thomas Forst
- Department of Endocrinology and Metabolic DiseasesUniversitatsmedizin der Johannes GutenbergMainzGermany
- Clinical Research ServicesManhheimGermany
| | - Pratik Choudhary
- Department of Diabetes and Nutritional SciencesKing's CollegeLondonUK
| | | | | | - Paolo Pozzilli
- Department of Endocrinology and Metabolic DiseasesUniversità Campus Bio‐MedicoRomeItaly
- Centre of ImmunobiologyBarts and the London School of MedicineQueen Mary University of LondonUK
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Peimani M, Garmaroudi G, Stewart AL, Yekaninejad M, Shakibazadeh E, Nasli-Esfahani E. Patient-physician interpersonal processes of care at the time of diabetes treatment intensification and their links to patient outcomes. PATIENT EDUCATION AND COUNSELING 2021; 104:1659-1667. [PMID: 33431242 DOI: 10.1016/j.pec.2020.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/05/2020] [Accepted: 12/13/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To investigate how patient-physician interpersonal processes of care are related to levels of diabetes-related distress, diabetes medication-taking behavior, and HbA1c during conversations with patients about intensifying medication. METHODS We randomly recruited 1270 patients from diabetes specialty clinics in Tehran, Iran who were taking an additional oral diabetes medication or starting insulin during the prior 3 months. This interviewer-administered cross-sectional survey assessed multiple aspects of patient-physician interpersonal processes, diabetes-related distress, and diabetes medication-taking. Clinical history and HbA1c were collected from electronic medical records. Regression estimates and Structural Equation Modeling were used to test associations. RESULTS Some communication scales indicated a significant relationship with total diabetes distress (P < 0.001). Diabetes medication-taking was associated with less diabetes distress (adjusted odds ratio [aOR]=0.45, P < 0.001), lower Hurried Communication (aOR=0.72, P = 0.013), higher Elicited Concerns (aOR=1.30, P = 0.012), and higher Explained Results (aOR=1.41, P < 0.001) scores. SEM analyses showed medication-taking behavior was associated with a 0.68 decrease in HbA1c. Hurried Communication and diabetes distress were directly associated with HbA1c. CONCLUSION Aspects of patient-physician interpersonal processes at the time of intensifying diabetes treatment may be related to experiencing less distress, effective medication-taking, and improved HbA1c. PRACTICE IMPLICATIONS The results are intended to inform communication strategies that physicians might incorporate into practice.
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Affiliation(s)
- Maryam Peimani
- Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Gholamreza Garmaroudi
- Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Anita L Stewart
- Center for Aging in Diverse Communities, University of California San Francisco, San Francisco, CA, USA; Institute for Health & Aging, University of California San Francisco, San Francisco, CA, USA.
| | - MirSaeed Yekaninejad
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Elham Shakibazadeh
- Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ensieh Nasli-Esfahani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Snoek FJ, Fisher L, Polonsky WH, Stuckey H, Hessler D, Tang T, Hermanns N, Mundet X, Silva M, Sturt J, Okazaki K, Hadjiyianni I, Desai U, Perez-Nieves M. Overcoming psychological insulin resistance: A practical guide for healthcare professionals. Prim Care Diabetes 2021; 15:619-621. [PMID: 33785288 DOI: 10.1016/j.pcd.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
Despite the demonstrated benefits of using insulin, nearly a third of the patients with type 2 diabetes (T2D) are initially reluctant to initiate insulin therapy when it is first recommended by their healthcare provider (HCP). Several studies have documented the reasons for this phenomenon known as psychological insulin resistance (PIR) and also identified actionable strategies for HCPs to assist people with T2D to overcome their PIR. However, most strategies are based on the experiences of HCPs, rather than of patients. Based on findings from a study exploring real-world patient experience around HCP actions for mitigating PIR, we suggest that HCPs use collaborative strategies throughout the course of T2D treatment to 1) explore reasons for PIR, 2) help patients overcome PIR, and 3) follow-up regarding experience with insulin.
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Affiliation(s)
- Frank J Snoek
- Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lawrence Fisher
- University of California, San Francisco, San Francisco, CA, USA
| | - William H Polonsky
- Behavioral Diabetes Institute, San Diego, CA, USA; University of California, San Diego, La Jolla, CA, USA
| | | | | | - Tricia Tang
- University of British Columbia, Vancouver, Canada
| | | | - Xavier Mundet
- Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Maria Silva
- Instituto Multidisciplinar de Medicina, Sao Paulo, Brazil
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Chan JCN, Gagliardino JJ, Ilkova H, Lavalle F, Ramachandran A, Mbanya JC, Shestakova M, Dessapt-Baradez C, Chantelot JM, Aschner P. One in Seven Insulin-Treated Patients in Developing Countries Reported Poor Persistence with Insulin Therapy: Real World Evidence from the Cross-Sectional International Diabetes Management Practices Study (IDMPS). Adv Ther 2021; 38:3281-3298. [PMID: 33978906 PMCID: PMC8189989 DOI: 10.1007/s12325-021-01736-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/30/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Although poor adherence to insulin is widely recognised, periodic discontinuation of insulin may cause more severe hyperglycaemia than poor adherence. We assessed persistence with insulin therapy in patients with type 1 (T1D) or type 2 diabetes (T2D) in developing countries and the reasons for insulin discontinuation. METHODS The International Diabetes Management Practices Study collected real-world data from developing countries in seven waves between 2005 and 2017. In Wave 7 (2016-2017), we asked adult patients with T1D and insulin-treated T2D to report whether they had ever discontinued insulin, the estimated duration of discontinuation and underlying reasons. RESULTS Among 8303 patients recruited from 24 countries by 620 physicians, 4596 were insulin-treated (T1D: 2000; T2D: 2596). In patients with T1D, 14.0% (95% CI: 12.5-15.6) reported having self-discontinued insulin for a median duration of 1.0 month (IQR: 0.5, 3.5). The respective figures in patients with T2D were 13.7% (12.4-15.1) and 2.0 months (IQR: 1.0, 6.0). The main reasons for discontinuation were impact on social life (T1D: 41.0%; T2D: 30.5%), cost of medications and test strips (T1D: 34.4%; T2D: 24.5%), fear of hypoglycaemia (T1D: 26.7%; T2D: 28.0%) and lack of support (T1D: 26.4%; T2D: 25.9%). Other factors included age < 40 years, non-university education and short disease duration (T1D: ≤ 1 year; T2D: > 1-≤ 5 years). Patients with T1D who did not perform self-monitoring of blood glucose (SMBG) or self-adjust their insulin dosage, and patients with T1D or T2D without glucose meters were less likely to persist with insulin. Nearly 50% of patients who reported poor persistence had HbA1c > 75 mmol/mol (> 9%) and > 50% of physicians recommended diabetes education programmes to improve treatment persistence. CONCLUSION In developing countries, poor persistence with insulin is common among insulin-treated patients, supporting calls for urgent actions to ensure easy access to insulin, tools for SMBG and education.
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Affiliation(s)
- Juliana C N Chan
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
| | - Juan José Gagliardino
- CENEXA, Center of Experimental and Applied Endocrinology (La Plata National University-La Plata National Scientific and Technical Research Council), La Plata, Argentina
| | - Hasan Ilkova
- Division of Endocrinology Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Fernando Lavalle
- Facultad de Medicina de la Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Ambady Ramachandran
- India Diabetes Research Foundation, Dr. A. Ramachandran's Diabetes Hospitals, Chennai, India
| | - Jean Claude Mbanya
- Biotechnology Center, Doctoral School of Life Sciences, Health and Environment, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Marina Shestakova
- Endocrinology Research Center, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | | | - Pablo Aschner
- Javeriana University School of Medicine, Bogotá, Colombia
- San Ignacio University Hospital, Bogotá, Colombia
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Balogh EG, Perez-Nieves M, Cao D, Hadjiyianni II, Ashraf N, Desai U, Snoek FJ, Sturt JA. Key Strategies for Overcoming Psychological Insulin Resistance in Adults with Type 2 Diabetes: The UK Subgroup in the EMOTION Study. Diabetes Ther 2020; 11:1735-1744. [PMID: 32562245 PMCID: PMC7376995 DOI: 10.1007/s13300-020-00856-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Indexed: 04/20/2023] Open
Abstract
INTRODUCTION Many patients with type 2 diabetes mellitus (T2DM) delay initiation of insulin therapy despite healthcare professional (HCP) advice. This phenomenon has been referred to as 'psychological insulin resistance' (PIR), and various contributing factors have been identified. Studies discussing approaches to overcoming PIR are lacking. Our aim was to identify the key strategies used by HCPs that most helped adults with T2DM and PIR in the UK to initiate insulin. METHODS As part of a global study, UK adults with T2DM and PIR were recruited (N = 125) to take a survey that included 38 HCP statements and actions about insulin initiation. Data assessed were perceived occurrence and helpfulness of these strategies in facilitating insulin initiation. RESULTS The most helpful strategies involved demonstrating the injection process (e.g. HCP talked patient through the process of taking insulin [83.6%]) and adopting a collaborative approach (HCP encouraged patient to contact the clinic immediately in case of any problems/questions [80.5%]). Additionally, HCPs highlighting the benefits of insulin (HCP explained that insulin was a natural substance needed by patient's body [81.2%]) and allaying patients' concerns (HCP explained that patient might not have to take insulin forever [78.0%]) helped patients initiate insulin. The least helpful action was HCPs repeatedly persuading patients to initiate insulin (40.9%). CONCLUSIONS The study recommends key strategies that HCPs can adopt to help adults with T2DM overcome PIR in the UK.
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Affiliation(s)
| | | | | | | | | | | | - Frank J Snoek
- Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Jackie A Sturt
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Shingaki T, Taki K, Koyanagi M, Nagaoka S, Yoshizawa K, Oki N, Yoshikawa A, Imaoka T. Long-term safety and effectiveness of biosimilar insulin glargine in Japanese patients with diabetes mellitus in routine clinical practice: results of a post-marketing safety study. Curr Med Res Opin 2020; 36:947-958. [PMID: 32271092 DOI: 10.1080/03007995.2020.1754182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: To evaluate the long-term safety and effectiveness of biosimilar insulin glargine (GLY) in real-world clinical practice.Methods: This prospective, non-interventional, multicenter, observational, post-marketing safety study (PMSS) enrolled Japanese patients with type 1 or 2 diabetes mellitus (T1DM or T2DM) starting GLY therapy, and was required by Japanese Pharmaceutical Affairs Law mandating post-marketing safety surveillance to acquire safety and effectiveness data of biosimilar products. Data collected from the 12-month observation included patient characteristics, adverse events, and blood glucose control.Results: The study enrolled 141 patients with T1DM and 1104 patients with T2DM. Pre-study insulin was used by 94.1% of patients with T1DM and 75.0% with T2DM. 65.4% of patients with T1DM and 64.3% with T2DM switched from the reference product (GLY-switched), while 25.0% with T2DM were insulin-naive. Adverse events were reported by 5.7% and 8.5% in T1DM and T2DM, respectively. Similar incidences were reported in GLY-switched. Adverse events were reported by 10.7% in insulin-naive T2DM. Baseline mean hypoglycemic events/month were 1.8 and 0.1 in T1DM and T2DM, respectively: the mean change from baseline (CFB) was -1.2 (p = .066) and 0.0 (p = .915), respectively. Baseline mean HbA1c was 8.4% and 8.7% in T1DM and T2DM, respectively; the mean CFB was -0.5% (p < .001) and -0.9% (p < .001), respectively, and -1.5% (p < .001) in insulin-naive T2DM.Conclusions: This first long-term Japanese PMSS of GLY demonstrated adverse events, hypoglycemia, and glycemic control consistent with the known GLY profile for T1DM and T2DM patients, in routine clinical practice.
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Affiliation(s)
| | - Kentaro Taki
- Medicines Development Unit-Japan, Eli Lilly Japan K. K, Kobe, Japan
| | - Momoha Koyanagi
- Medicines Development Unit-Japan, Eli Lilly Japan K. K, Kobe, Japan
| | - Soshi Nagaoka
- Medicines Development Unit-Japan, Eli Lilly Japan K. K, Kobe, Japan
| | | | - Norika Oki
- Medicines Development Unit-Japan, Eli Lilly Japan K. K, Kobe, Japan
| | - Aki Yoshikawa
- Medicines Development Unit-Japan, Eli Lilly Japan K. K, Kobe, Japan
| | - Takeshi Imaoka
- Medicines Development Unit-Japan, Eli Lilly Japan K. K, Kobe, Japan
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12
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Turchin A, Hosomura N, Zhang H, Malmasi S, Shubina M. Predictors and consequences of declining insulin therapy by individuals with type 2 diabetes. Diabet Med 2020; 37:814-821. [PMID: 32077139 DOI: 10.1111/dme.14260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 12/01/2022]
Abstract
AIM To determine the relationship between decline of insulin therapy by individuals with type 2 diabetes and subsequent blood glucose control. METHODS We retrospectively studied adults with type 2 diabetes and suboptimal (HbA1c ≥ 53 mmol/mol [7.0%]) glycaemic control followed at two academic hospitals between 2000 and 2014 who were recommended insulin therapy. Decline of insulin therapy recommendations was identified using natural language processing of provider notes. Time to HbA1c < 53 mmol/mol (7.0%) served as the primary outcome. RESULTS Of 5307 study participants, 2267 (42.7%) declined insulin therapy. Median time to HbA1c control in individuals who declined vs. started insulin therapy was 50 vs. 38 months, respectively (P < 0.001). In multivariable analysis, decline of insulin therapy was associated with hazard ratio for HbA1c control of 0.89 (95% CI 0.82 to 0.97; P = 0.008). Participants were more likely to accept insulin therapy recommendations if they had diabetes complications (OR 1.32; 95% CI 1.13 to 1.53; P < 0.001) or a higher HbA1c (OR 1.10; 95% CI 1.07 to 1.13; P < 0.001), and less likely if they were older (OR 0.81; 95% CI 0.76 to 0.86; P < 0.001) or were taking more non-insulin diabetes medications (OR 0.78; 95% CI 0.74 to 0.83; P < 0.001). CONCLUSIONS Individuals with uncontrolled type 2 diabetes who declined insulin therapy subsequently had worse glycaemic control. These findings highlight the need to improve our understanding of the relationship of this common but poorly explored clinical phenomenon to blood glucose control and ultimately diabetes complications.
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Affiliation(s)
- A Turchin
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - N Hosomura
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - H Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - S Malmasi
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - M Shubina
- Brigham and Women's Hospital, Boston, Massachusetts
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13
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Abstract
Factors contributing to therapeutic inertia related to patients' medication experiences include concerns about side effects and out-of-pocket costs, stigmatization for having diabetes, confusion about frequent changes in evidence-based guidelines, low health literacy, and social determinants of health. A variety of solutions to this multifactorial problem may be necessary, including integrating pharmacists into interprofessional care teams, using medication refill synchronization programs, maximizing time with patients to discuss fears and concerns, being cognizant of language used to discuss diabetes-related topics, and avoiding stigmatizing patients. Managing diabetes successfully is a team effort, and the full commitment of all team members (including patients) is required to achieve desired outcomes through an individualized approach.
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Affiliation(s)
| | - John E Begert
- School of Pharmacy, Pacific University Oregon, Hillsboro, OR
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14
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Guzman SJ. A Behavioral Perspective of Therapeutic Inertia: A Look at the Transition to Insulin Therapy. Diabetes Spectr 2020; 33:38-43. [PMID: 32116452 PMCID: PMC7026761 DOI: 10.2337/ds19-0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
From a behavioral perspective, therapeutic inertia can happen when obstacles to changing a diabetes treatment plan outweigh perceived benefits. There is a complex interaction of important treatment-related obstacles for people with diabetes (PWD), their treating health care professional (HCP), and the clinical setting in which they interact. Tipping the scales toward more effective action involve strategies that increase perceptions of the benefits of treatment intensification while addressing important obstacles so that treatment changes are seen by both PWD and HCPs as worthwhile and achievable.
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15
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Upsher R, Allen-Taylor M, Reece I, Chamley M, Ismail K, Forbes A, Winkley K. Experiences of Attending Group Education to Support Insulin Initiation in Type 2 Diabetes: A Qualitative Study. Diabetes Ther 2020; 11:119-132. [PMID: 31732858 PMCID: PMC6965558 DOI: 10.1007/s13300-019-00727-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Type 2 diabetes is a progressive condition and many people require insulin therapy 5-10 years post diagnosis. Considering the global increase in type 2 diabetes, group education programmes to initiate insulin are beneficial as they are cost-effective and provide peer support. However, group education to initiate insulin has not been widely evaluated and there is a need to elicit the views and experience of people with type 2 diabetes who start insulin in groups. The aim of this study was to explore the perspectives of people with type 2 diabetes who receive nurse-led group-based insulin education. METHODS Qualitative, semi-structured interviews of people with type 2 diabetes in south London, UK, who had attended group education sessions to start insulin. Inductive thematic analysis identified themes within the data. RESULTS Fifteen people with type 2 diabetes were interviewed. Three main themes were identified: creating a supportive environment; facilitator skills; and effectiveness of group. Factors which created a supportive environment included peer support, providing reassurance and printed materials. Facilitator skills associated with positive experiences included addressing negative insulin beliefs and managing group dynamics. The effectiveness of the group was determined by ongoing self-management success, need for more peer support, and insulin concerns post insulin education group. CONCLUSION Positive experiences of insulin group education for people with type 2 diabetes were associated with sharing experiences with other people starting insulin, reassurance from healthcare professionals, appropriate supportive materials, and skill of the facilitator to address insulin concerns and manage group dynamics. People with type 2 diabetes may benefit more from education if healthcare professionals are skilled in psychological techniques to facilitate group education aimed at addressing concerns around insulin therapy. Further research needs to assess the effectiveness of structured insulin group education for people with type 2 diabetes.
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Affiliation(s)
- Rebecca Upsher
- Diabetes, Psychiatry, and Psychology, Department of Psychological Medicine, King's College London and Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Maya Allen-Taylor
- Florence Nightingale Faculty of Nursing and Midwifery and Palliative Care, King's College London, London, UK
| | - Ilse Reece
- Florence Nightingale Faculty of Nursing and Midwifery and Palliative Care, King's College London, London, UK
| | - Mark Chamley
- Lambeth Clinical Commissioning Group Diabetes Intermediate Care Team, South London, London, UK
| | - Khalida Ismail
- Diabetes, Psychiatry, and Psychology, Department of Psychological Medicine, King's College London and Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Angus Forbes
- Florence Nightingale Faculty of Nursing and Midwifery and Palliative Care, King's College London, London, UK
| | - Kirsty Winkley
- Florence Nightingale Faculty of Nursing and Midwifery and Palliative Care, King's College London, London, UK
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Stuckey H, Fisher L, Polonsky WH, Hessler D, Snoek FJ, Tang TS, Hermanns N, Mundet-Tuduri X, da Silva MER, Sturt J, Okazaki K, Cao D, Hadjiyianni I, Ivanova JI, Desai U, Perez-Nieves M. Key factors for overcoming psychological insulin resistance: an examination of patient perspectives through content analysis. BMJ Open Diabetes Res Care 2019; 7:e000723. [PMID: 31908792 PMCID: PMC6936574 DOI: 10.1136/bmjdrc-2019-000723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/17/2019] [Accepted: 10/01/2019] [Indexed: 11/04/2022] Open
Abstract
Objective To understand participant perceptions about insulin and identify key behaviors of healthcare professionals (HCPs) that motivated initially reluctant adults from seven countries (n=40) who had type 2 diabetes (T2D) to start insulin treatment. Research design and methods Telephone interviews were conducted with a subset of participants from an international investigation of adults with T2D who were reluctant to start insulin (EMOTION). Questions related to: (a) participants' thoughts about insulin before and after initiation; (b) reasons behind responses on the survey that were either 'not helpful at all' or 'helped a lot'; (c) actions their HCP may have taken to help start insulin treatment; and (d) advice they would give to others in a similar situation of starting insulin. Responses were coded by two independent reviewers (kappa 0.992). Results Starting insulin treatment was perceived as a negative experience that would be painful and would lead down a 'slippery slope' to complications. HCPs engaged in four primary behaviors that helped with insulin acceptance: (1) showed the insulin pen/needle and demonstrated the injection process; (2) explained how insulin could help with diabetes control and reduce risk of complications; (3) used collaborative communication style; and (4) offered support and willingness to answer questions so that participants would not be 'on their own'. Following initiation, most participants noted that insulin was not 'as bad as they thought' and recommended insulin to other adults with T2D. Conclusions Based on these themes, two actionable strategies are suggested for HCPs to help people with psychological insulin resistance: (1) demonstrate the injection process and discuss negative perceptions of insulin as well as potential benefits; (2) offer autonomy in a person-centred collaborative approach, but provide support and accessibility to address concerns. These findings help HCPs to better understand ways in which they can engage reluctant people with T2D with specific strategies.
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Affiliation(s)
| | - Lawrence Fisher
- University of California San Francisco, San Francisco, California, USA
| | - William H Polonsky
- Behavioral Diabetes Institute, University of California, San Diego, Del Mar, California, USA
| | - Danielle Hessler
- University of California San Francisco, San Francisco, California, USA
| | - Frank J Snoek
- Amsterdam University Medical Centre Vrije Universiteit, Amsterdam, The Netherlands
| | - Tricia S Tang
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Kentaro Okazaki
- Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Dachuang Cao
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Urvi Desai
- Analysis Group Inc Boston, Boston, Massachusetts, USA
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17
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Bloomgarden Z. ADA2019. J Diabetes 2019; 11:778-780. [PMID: 31250543 DOI: 10.1111/1753-0407.12965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Zachary Bloomgarden
- Department of Medicine, Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York
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18
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Okazaki K, Shingaki T, Cai Z, Perez-Nieves M, Fisher L. Successful Healthcare Provider Strategies to Overcome Psychological Insulin Resistance in Japanese Patients with Type 2 Diabetes. Diabetes Ther 2019; 10:1823-1834. [PMID: 31286432 PMCID: PMC6778551 DOI: 10.1007/s13300-019-0664-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION EMOTION was a multinational, noninterventional study surveying current insulin-using adults with type 2 diabetes mellitus (T2D) who were initially reluctant to begin insulin treatment. In this Japanese population subanalysis of EMOTION, we identify the frequency and level of helpfulness of healthcare provider (HCP) actions, and we analyze life events ('actions/events') that assist T2D patients with psychological insulin resistance in the decision to initiate insulin. METHODS Participants were selected from Survey Sampling International and their local partners' market research panels in Japan. Quantitative surveys were administered between December 2016 and August 2017 to patients who met the study criteria. Participants were asked whether 45 actions/events occurred, and to rate the level of helpfulness of the actions/events in contributing to their decision to initiate insulin. RESULTS Among the 594 eligible participating adults in the EMOTION study, 99 were from Japan. Despite initial reluctance to begin insulin treatment, 80.8% of the Japanese participants immediately commenced insulin. Practical demonstrations by HCPs on how to use insulin were rated by participants as most helpful. Examples of such practical demonstrations, reported as helping moderately or a lot, were 'HCP walked patient through the process of exactly how to take insulin' (82.8%), 'HCP showed an insulin pen' (79.7%), and 'HCP helped patient to see how simple it was to inject insulin' (79.1%). CONCLUSION This study identifies actions that HCPs can use to assist Japanese patients in deciding whether to initiate insulin. These findings may aid the development of clinical interventions addressing reluctance to begin insulin treatment among Japanese patients with T2D. FUNDING Eli Lilly and Company and Boehringer Ingelheim. Plain language summary available for this article.
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Affiliation(s)
- Kentaro Okazaki
- Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tomotaka Shingaki
- Eli Lilly Japan K.K., 5-1-28 Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan.
| | - Zhihong Cai
- Eli Lilly Japan K.K., 5-1-28 Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan
| | | | - Lawrence Fisher
- Behavioral Diabetes Institute, 5405 Oberlin Drive Suite 100, San Diego, CA, 92121, USA
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