Decision-making: initiating insulin therapy for adults with diabetes

Review of insulin therapy and pen use in hospitalized patients

OBJECTIVE

Hyperglycemia is common among hospitalized patients, affecting approximately 40% of patients at the time of hospital admission, despite the fact that 1 in every 8 patients has no previous diagnosis of diabetes. Hyperglycemia has been associated with poor patient outcomes, including higher rates of morbidity and mortality across a range of conditions. This review discusses options for the effective management of hyperglycemia with a focus on the use of disposable insulin pens in the hospital.

METHODS

Literature, including guidelines for hospital management of hyperglycemia, and information regarding methods of insulin administration were reviewed.

RESULTS

Appropriate glucose control via administration of insulin within hospitals has been acknowledged as an important goal and is consistent with achieving patient safety. Insulin may be administered subcutaneously using a pen or vial and syringe or infused intravenously. Levels of patient and provider satisfaction are higher with pen administration than with vial and syringe. Insulin pens have many safety and convenience features including enhanced dose accuracy and autocover/autoshield pen needles.

CONCLUSION

Use of insulin pens instead of vials and syringes can provide several advantages for hospitalized patients, including greater satisfaction among them and health care providers, improved safety, and reduced costs. These advantages can continue following patient discharge.

Researching involvement in health care practices: interrupting or reproducing medicalization?

In this paper we reflect upon and problematize the ways in which 'patient involvement' is interpreted in a substantial proportion of the research literature on involvement and shared decision making. Drawing upon an analysis of this literature we raise concerns about the 'medicalization of involvement' embedded in, and reproduced by, some dominant research lenses, suggesting that this medicalization has powerful discursive and material effects. For example, we suggest that it tends to normalize and arguably trivialize intrinsically problematic and contentious concepts such as 'patient preferences' and, at the same time, to obscure the full range of possibilities for reciprocity in the exchanges between the medical world of the professional and the experiential and narrative world of the patient. We argue that richer conceptualizations of collaboration in clinical work are both possible and very much needed, and we indicate some examples of scholarly resources and perspectives that point towards richer and more defensible accounts of involvement. Overall we call for more attention to the idea of 'epistemic involvement' and much greater cross-fertilization between different epistemological paradigms in this area of research.

Reusable and disposable insulin pens for the treatment of diabetes: understanding the global differences in user preference and an evaluation of inpatient insulin pen use

Insulin is essential for the management of type 1 diabetes and is more commonly being used for the treatment of type 2 diabetes. Insulin pen devices were first introduced over 20 years ago and have evolved to provide significant practical advantages compared with the vial and syringe. Pen devices are now used by patients with diabetes worldwide, but there are marked geographical variations in the use of reusable and disposable pens. In some countries the vial and syringe is still the most popular method of administering insulin, whereas in other countries the use of reusable or disposable pens is more prevalent. Therefore, the aim of this review is to discuss the factors that seem to be involved in these differences, which include patient access to insulin, cost, and physician/patient awareness and preference. Inpatient use of insulin is also common, and the use of insulin pens could offer substantial benefits in this patient population, not only during the admission period but also after discharge from the hospital. However, the evidence base for inpatient use is still weak, and more studies are needed to investigate the use of insulin pens in this patient population.