Charlotte R Kuo1, Judy Quan2,3, Sarah Kim4,5, Audrey Hui-Yu Tang6, Deborah Payne Heuerman7, Elizabeth J Murphy4,5. 1. Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. 2. Division of General Internal Medicine, University of California, San Francisco, CA, USA. 3. UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. 4. University of California, San Francisco, CA, USA. 5. Division of Endocrinology, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. 6. Family Health Center, Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. 7. General Medicine Clinic, Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Abstract
AIMS AND OBJECTIVES: To evaluate the effect of an 'insulin introduction' group visit on insulin initiation and A1C in adults with type 2 diabetes. BACKGROUND: The clinical course of type 2 diabetes involves eventual beta-cell failure and the need for insulin therapy. Patient psychological insulin resistance, provider-related delays and system barriers to timely initiation of insulin are common. Group visits are widely accepted by patients and represent a potential strategy for improving insulin initiation. DESIGN: A single two-hour group visit in English or Spanish, facilitated by advanced practice nurses, addressed psychological insulin resistance and encouraged mock injections to overcome needle anxiety. METHODS: A retrospective review of 273 patients referred from 2008-2012, determined characteristics of group attenders, rates of mock self-injection, rates of insulin initiation and changes in A1C from baseline to 2-6 and 7-12 months postgroup. Change in A1C was compared to patients referred to the group who did not attend ('nonattenders'). RESULTS: Of 241 patients eligible for analysis, 87·6% were racial/ethnic minorities with an average A1C of 9·99%. Group attendance rate was 66%; 92% performed a mock injection, 55% subsequently started insulin. By 2-6 months, A1C decreased by 1·37% among group attenders, and by 1·6% in those who did a mock injection and started insulin. Fewer nonattenders started insulin in primary care (40%), experiencing an A1C reduction of 0·56% by 2-6 months. A1C improvements were sustained by 7-12 months among group attenders and nonattenders who started insulin. RELEVANCE TO CLINICAL PRACTICE: Nurses can effectively address patient fears and engage patients in reframing insulin therapy within group visits. CONCLUSIONS: This one-time nurse-facilitated group visit addressing psychological barriers to insulin in a predominantly minority patient population resulted in increased insulin initiation rates and clinically meaningful A1C reductions.
AIMS AND OBJECTIVES: To evaluate the effect of an 'insulin introduction' group visit on insulin initiation and A1C in adults with type 2 diabetes. BACKGROUND: The clinical course of type 2 diabetes involves eventual beta-cell failure and the need for insulin therapy. Patientpsychological insulin resistance, provider-related delays and system barriers to timely initiation of insulin are common. Group visits are widely accepted by patients and represent a potential strategy for improving insulin initiation. DESIGN: A single two-hour group visit in English or Spanish, facilitated by advanced practice nurses, addressed psychological insulin resistance and encouraged mock injections to overcome needle anxiety. METHODS: A retrospective review of 273 patients referred from 2008-2012, determined characteristics of group attenders, rates of mock self-injection, rates of insulin initiation and changes in A1C from baseline to 2-6 and 7-12 months postgroup. Change in A1C was compared to patients referred to the group who did not attend ('nonattenders'). RESULTS: Of 241 patients eligible for analysis, 87·6% were racial/ethnic minorities with an average A1C of 9·99%. Group attendance rate was 66%; 92% performed a mock injection, 55% subsequently started insulin. By 2-6 months, A1C decreased by 1·37% among group attenders, and by 1·6% in those who did a mock injection and started insulin. Fewer nonattenders started insulin in primary care (40%), experiencing an A1C reduction of 0·56% by 2-6 months. A1C improvements were sustained by 7-12 months among group attenders and nonattenders who started insulin. RELEVANCE TO CLINICAL PRACTICE: Nurses can effectively address patient fears and engage patients in reframing insulin therapy within group visits. CONCLUSIONS: This one-time nurse-facilitated group visit addressing psychological barriers to insulin in a predominantly minority patient population resulted in increased insulin initiation rates and clinically meaningful A1C reductions.
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