Resource utilisation and quality of life following initiation of insulin detemir in patients with type 2 diabetes mellitus

Changes of health-related quality of life after initiating basal insulin treatment among people with type 2 diabetes

To assess the association between insulin regimens and health-related quality of life (HRQoL) after the introduction of basal insulin (BI) among people with type 2 diabetes in real-world clinical settings. 16,339 registered people with diabetes who had inadequate glycaemic control by oral agents initiated BI (either single BI or Basal-bolus) and completed a 6-month follow-up from 209 hospitals were included in the analyses. At the end of the follow-up, the switches of insulin regimens, change of HRQoL (EQ-5D-3L) and their associations were assessed. Initial insulin regimens of single BI and of basal-bolus (BI included Glargine, Detemir, and Neutral Protamine Hagedorn) accounted for 75.6% and 24.4%, respectively. At 6 months, regimens used were BI alone (65.2%), basal-bolus (10.4%), and premixed (6.4%), whereas 17.9% stopped all insulin therapy. The visual analogue scale score increased by 5.46 (P < .001), and the index value increased slightly by 0.02 (P < .001). Univariate analysis showed that people with diabetes taking basal-bolus regimen had the greatest improvement on HRQoL in all dimensions, especially in the reduction of the percentage of Pain/Discomfort (by 10.03%) and Anxiety/Depression (by 11.21%). In multivariable analysis, single BI or premixed insulin at 6 months was associated with more improvement of visual analogue scale score compared with stopping all insulin. Improved HRQoL was observed after initiating BI in people with type 2 diabetes . If the same achievement on HbA1c control can be guaranteed, single BI is preferred to other regimens from the viewpoint of HRQoL. Basal-bolus has the most significant potential to increase HRQoL, however, the people with diabetes characteristics differ from those initiating BI alone. Further longitudinal cohort study with a longer study period might be necessary to evaluate the certain effect.

100 years on: the impact of the discovery of insulin on clinical outcomes

Throughout history, up to the early part of the 20th century, diabetes has been a devastating disorder, particularly when diagnosed in childhood when it was usually fatal. Consequently, the successful pancreatic extraction of insulin in 1921 was a miraculous, life-changing advance. In this review, the truly transformative effect that insulin has had on the lives of people with type 1 diabetes and on those with type 2 diabetes who are also dependent on insulin is described, from the time of its first successful use to the present day. We have highlighted in turn how each of the many facets of improvements over the last century, from advancements in the properties of insulin and its formulations to the evolution of different methods of delivery, have led to continued improvement in clinical outcomes, through the use of illustrative stories from history and from our own clinical experiences. This review concludes with a brief look at the current challenges and where the next century of technological innovation in insulin therapy may take us.

The burden of type 2 diabetes in Europe: Current and future aspects of insulin treatment from patient and healthcare spending perspectives

Due to the progressive nature of type 2 diabetes (T2DM), initiation of insulin therapy is very likely in the disease continuum. This article aims at highlighting the current situation with regard to insulin therapy in people with T2DM in Europe and at presenting the associated unmet need. Challenges for both people with T2DM and healthcare professionals include clinical inertia also derived from fear of hypoglycaemia, weight gain and injections as well as increased need for a comprehensive diabetes management. We compare national and international guidelines and recommendations for the initiation and intensification of insulin therapy with the real-world situation in six European countries, demonstrating that glycaemic targets are only met in a minority of people with T2DM on insulin therapy. Furthermore, this work evaluates currently recorded numbers of people with T2DM treated with insulin in Europe, the proportion not achieving the stated glycaemic targets and thus in need to enhance insulin therapy e.g. by a change in means of insulin delivery including, but not limited to, insulin pens, wearable mealtime insulin delivery patches, patch pumps, and conventional insulin pumps with continuous subcutaneous insulin infusion.

The relationship between intensification of blood glucose-lowering therapies, health status and quality of life in type 2 diabetes: The Fremantle Diabetes Study Phase II

AIMS

To determine whether therapeutic intensification in type 2 diabetes influences health status and quality of life (QoL).

METHODS

We studied 930 participants in the longitudinal observational Fremantle Diabetes Study Phase II (mean age 65.3 years, 53.8% males, median diabetes duration 8.0 years) with valid data from baseline assessment and two biennial reviews (4 years of follow-up) between 2008 and 2015. The main outcome measures were the Short Form-12 version 2 physical and mental health composite scores (PCS, MCS) and the average weighted impact (AWI) score from the Audit of Diabetes Dependent QoL.

RESULTS

There were reductions in PCS at Year 4 compared with baseline and Year 2 in patients on stable diet-based management (n = 160), oral glucose-lowering medication (OGLM; n = 387), and insulin with/without OGLM (n = 168; P < 0.05), but no statistically significant temporal changes in MCS/AWI. Insulin-treated patients had the lowest PCS, MCS and AWI compared to the other two subgroups at each time-point (P ≤ 0.012). In participants initiating OGLM (n = 84) or insulin (n = 85), there were no differences in PCS, MCS or AWI at the biennial assessments either side of these therapeutic changes (P ≥ 0.08).

CONCLUSIONS

These real-life data show that treatment intensification, including insulin initiation, does not impact adversely on patient well-being in community-based type 2 diabetes. Since insulin use at entry was associated with longer diabetes duration, worse glycaemic control, and a greater risk of chronic complications, the burden of disease rather than treatment modality appears the primary determinant of health status and QoL.

Peer Education Group Intervention to Reduce Psychological Insulin Resistance: A Pilot Mixed-Method Study in a Chinese Population

INTRODUCTION

Psychological insulin resistance (PIR) is common among type II diabetes (DM) patients. Although interventions to reduce PIR have been suggested, there is no standardized intervention to reduce PIR. This trial aimed to assess the preliminary effectiveness of a well-structured interventional patient group (for sample size calculation for larger trials), as well as the acceptability and feasibility of this intervention group.

METHODS

This study used a quasi-experimental, mixed-method approach. Fifty-three patients with DM were recruited to an interventional group that included a general education of DM and insulin, an insulin pen demonstration, and an insulin-using peer sharing session. Each group consisted of around 15 participants and lasted for 2 h each. The validated Chinese version of the insulin treatment appraisal scale (C-ITAS) was administered before, immediately after, and 1 month after the intervention to measure any changes in the participants' PIR. Patients were interviewed to assess the acceptability of the intervention until data saturation.

RESULTS

Repeated measures ANOVA showed that the post-intervention C-ITAS scores (immediately post group and at 1 month) were lower than the pre-intervention C-ITAS scores (p < 0.001). Changes in multiple attitudes toward insulin were detected before and after the group intervention. Ten patient interviews were conducted and found that the intervention was welcomed by all interviewees; no discomfort or adverse reactions were reported.

CONCLUSION

Preliminary results showed that patient intervention groups with general education, insulin pen demonstration, and peer sharing appeared to be safe, acceptable, and effective in reducing PIR. Larger multicenter trials are needed to generalize these findings.

Changes in health services usage associated with insulin initiation in primary care

Insulin initiation is often delayed in primary care partly because of clinician concerns about the additional clinical work. This study describes health services usage (HSU) pre- and post-insulin initiation in people with type 2 diabetes and out-of-target glycaemic levels. Secondary analysis of participant data from the Stepping Up randomised controlled trial of a model of care for insulin initiation in general practice was undertaken. For 142 people who commenced insulin, HSU in the 6 months prior was compared to that in the 12 months following insulin initiation. Overall, HSU events increased in the 6 months following insulin initiation from a median (IQR) of 18 (15, 29) to 23 (16, 36); (P=0.05), mostly because of an increase in general practitioner (GP) consultations (6 (4, 10) to 8 (5, 11); (P=0.01)). HSU and GP consultations subsequently returned to baseline at 12 months. There was no effect on hospitalisations or specialist consultations. Insulin initiation is associated with a small increase in GP consultations that reverts to baseline after 12 months without affecting other health services. This study can inform health services planning and resource allocation at practice and health policy levels to support insulin initiation in general practice.

Assessing Psychological Insulin Resistance in Type 2 Diabetes: a Critical Comparison of Measures

PURPOSE OF REVIEW

This study aims to examine the operationalisation of 'psychological insulin resistance' (PIR) among people with type 2 diabetes and to identify and critique relevant measures.

RECENT FINDINGS

PIR has been operationalised as (1) the assessment of attitudes or beliefs about insulin therapy and (2) hypothetical or actual resistance, or unwillingness, to use to insulin. Five validated PIR questionnaires were identified. None was fully comprehensive of all aspects of PIR, and the rigour and reporting of questionnaire development and psychometric validation varied considerably between measures. Assessment of PIR should focus on the identification of negative and positive attitudes towards insulin use. Actual or hypothetical insulin refusal may be better conceptualised as a potential consequence of PIR, as its assessment overlooks the attitudes that may prevent insulin use. This paper provides guidance on the selection of questionnaires for clinical or research purpose and the development of new, or improvement of existing, questionnaires.

Negative appraisals of insulin therapy are common among adults with Type 2 diabetes using insulin: Results from Diabetes MILES - Australia cross-sectional survey

AIM

To identify insulin therapy appraisals among adults with Type 2 diabetes using insulin and how negative appraisals relate to clinical, self-care and psychosocial outcomes.

METHODS

Diabetes MILES - Australia 2011 was a national survey of adults with diabetes, focused on behavioural and psychosocial issues. Subgroup analyses were conducted on the responses of 273 adults with Type 2 diabetes using insulin (46% women; mean ± sd age: 59 ± 9 years; diabetes duration: 12 ± 7 years; years using insulin: 4 ± 4). They completed validated measures of insulin therapy appraisals (ITAS), depression (PHQ-9), anxiety (GAD-7), diabetes distress (PAID) and diabetes-specific self-efficacy (DES-SF).

RESULTS

Insulin was perceived to be very important, and its benefits (e.g. improves health) were endorsed by most (82%). Fifty-one per cent believed that taking insulin means their diabetes has become worse; 51% that insulin causes weight gain; 39% that they have 'failed to manage' their diabetes. Those with the greatest and least 'ITAS negative' scores did not differ by diabetes duration or years using insulin, or by average number of insulin injections or blood glucose checks per day. Those with more negative insulin appraisals were significantly younger (Mean Diff. = 5 years, P < 0.001), less satisfied with recent blood glucose levels (P < 0.001, d = 0.63), had reduced diabetes-specific self-efficacy (P < 0.001, d = 0.7), and were more likely to report depressive symptoms, anxiety or diabetes distress (all P < 0.001, d = 0.65-1.1).

CONCLUSIONS

Negative insulin therapy appraisals are common among adults with Type 2 diabetes using insulin, and are associated with lower general and diabetes-specific emotional well-being, reduced diabetes-specific self-efficacy and satisfaction with blood glucose.