Evaluation on the effectiveness of Diabetes Nurse Clinic (DMNC) in treating patient who

needs initiation of insulin therapy

HA Convention 2017

Presented by Maisy Mok, NC (DM), KEC

Background

2015

2040 415 M

642 M

Diabetes Prevalence

IDF Diabetes Atlas (2015)

2015

2040 26.7 M

34.6 M

10.2%

7,375,000 (population, census & Statistic Depart, HK)

753,000

Number of DM patients under care of HA

Increased 100,000 (33.4%) at past 5 years

From evidence………

• Optimal glycemic control can prevent or delay the related complications

• DCCT – The Diabetes Control & Complications Trial (1993) • EDIC – Epidemiology of Diabetes Interventions and Complications (1999) • UKPDS – The UK Prospective Diabetes Study (1998) • 10 years follow up of Intensive Glucose Control in Type 2 Diabetes (2008)

Who needs initiation of insulin therapy??

Particular in - • Glucose toxicity • Suboptimal glycemic control with maximum oral hypoglycemic agents

Insulin Achieves the optimal glycemic control to prevent and delay the related complications

Resistance on starting insulin therapy

What’s insulin ? Why do I need injection?

Fear

Worry

Stress

DM Nurse Clinic : deal with patient’s concern and problem

Objective

• To evaluate the effectiveness of DMNC on diabetic patient who needs initiation of insulin therapy

Methodology

• Multi-centers – QMH, UCH, YCH • Intervention: Diabetes Self-management Education including teaching

insulin administration to patient or care-giver • Pre and post evaluation ( 9 months)

• Physical parameters – HbA1c, lipid profile & Body weight • Stress level - Diabetes Distress Screening Scale (DDSS) and Insulin Related

Stress Score (IRSS) • Behavior changes – Summary of Diabetes Self-Care Activities (SDSCA)

Diabetes Distress Screening Scale (DDSS)

Emotional Burden

1. 覺得糖尿病每天都消耗我大量心力和精力

3. 當想到患有糖尿病便覺得忿怒丶恐懼及／或憂慮

8. 覺得糖尿病控制了我的人生

11. 覺得我會承受嚴重的長期糖尿病併發症，不管如何努力去防止它的發生

14. 對糖尿病的生活限制感到沮喪

Physician-related Distress

2. 覺得我的醫生不夠了解糖尿病及糖尿護理

4. 覺得我的醫生沒有給我清楚的指引去管理我的糖 尿病

9. 覺得我的醫生沒有認真對待我的疑慮

15. 覺得我沒有一位醫生可長期跟進我的糖尿病

Regimen-related Distress

5. 覺得自己沒有緊密測試我的血糖水平

6. 覺得自己經常未能成功做到糖尿病的控制計劃

10. 對自己日常管理糖尿病的能力沒有信心

12. 覺得自己沒有緊跟良好的飲食指引

16. 覺得沒有動力去維持對糖尿病的自我控制

Interpersonal Distress

7. 覺得朋友或家人對我的自律不夠支持（例如籌備的活動將會與我的時 間表相冲，鼓勵我吃𡿨𡿨不該吃〉的食物）

13. 覺得朋友或家人不明白糖尿病人生活的苦況

17. 覺得朋友或家人沒有提供我所需要的情緒支援

Insulin Related Stress Score (IRSS)

胰島素治療焦慮評估表

1. 我害怕胰島素針，感到焦慮或憂心

2. 我對於要掌握胰島素注射技巧，感到焦慮或憂心

3. 我對於胰島素注射可能帶來的不方便，感到焦慮 或憂心

4. 我對於胰島素注射可能帶來的歧視，感到焦慮或 憂心

5. 我會因過往控制不好血糖而需要注射胰島素，感 到焦慮或憂心

Summary of Diabetes Self-Care Activities (SDSCA)

Summary of Diabetes Self-Care Activities (SDSCA) General Diet 1. 在過去七日，你有多少天跟隨健康的飲食計劃？

2. 在過一個月，平均每星期你有多少天跟隨健康的飲食計劃？

DM Specific Diet 3. 在過去七日，你有多少天進食五份或以上的生果和蔬菜？ 4. 在過去七日，你有多少天進食高脂肪食物如紅肉或全脂製成品？

Exercise 5. 在過去七日，你有多少天參與最少三十分鐘的體能活動？（持續的活 動，包括步行，並以分鐘計算） 6. 在過去七日，你有多少天刻意做一些運動（如：游泳、步行、騎單車） 而不是在家或工作之內呢？

Self-monitor of Blood Glucose

7. 在過去七日，你有多少天曾測試自己的血糖？ 8. 在過去七日，你有多少天曾按醫護人員建議的次數測試自己的血糖？

Foot Care 9. 在過去七日，你有多少天曾檢查自己的雙腳？ 10. 在過去七日，你有多少天清洗自己的雙腳？ 11. 在過去七日，你有多少天檢查你的鞋子的內部？

Anti-DM Drug Compliance 12. 在過去七日，你有多少天服食建議的糖尿藥丸？

Hypoglycaemia management

13. 在過去七日，你有多少天接受建議而外出時帶傋糖果傍身？

Smoking 14. 在過去七日，你曾否抽煙即使一口？

Result

• Total 130 participants were recruited with the following baseline characteristic

Personal data

Gender (Male / Female)

82 (63.1%) / 48 (36.9%)

Age (years) 60.5 ± 11.8

Duration of Diabetes (years)

11.9 ± 9.2

Marital status Married 98 (75.4%) Single 17 (13.1%)

Divorced / widowed

14 (10.7%)

Missing data 1 (0.8%)

Education level No formal education 9 (6.9%)

Primary 49 (37.7%) Secondary 64 (49.2%)

Tertiary or above 7 (5.4%) Missing data 1 (0.8%)

Smoking habit Non-smoked 72 (55.4%)

Current smoker 27 (20.8%) Ex-smoker 29 (22.3%)

Missing data 2 (1.5%)

Alcohol in-take Non-drinker 89 (68.5%)

Current drinker 3 (2.3%) Social drinker 37 (28.4%) Missing data 1 (0.8%)

Values are mean + standard deviation, or N (%)

Result - Glycaemic Control

• 10.1 ± 2.1% at baseline vs 7.9 ± 1.2% at the end of intervention, p< 0.001

Comparison of HbA1c levels before and after DMNC interventions

7.9 ± 1.2%

10.1 ± 2.1%

Lipid Profiles

Baseline End of study p value

Total Cholesterol (mmol/L) 4.6 ± 1.1 4.4 ± 1.0 0.095

Triglycerides (mmol/L) 2.4 ± 1.9 1.9 ± 1.2 <0.001*

LDL Cholesterol (mmol/L) 2.6 ± 1.0 2.4 ± 0.9 0.040*

HDL Cholesterol (mmol/L) 1.1 ± 0.3 1.2 ± 0.4 0.014*

Comparison of lipid profiles before and after DMNC intervention

Values are mean + standard deviation; * Significant difference with p < 0.05

Body Weight

66 68 70 72

After

Before

Body Weight

After

Before

69.48±7.5kg

70.35±7.43kg

• Minor, but significant increase at the end of the intervention (mean increase= 0.861, 95% CI= 1.25 to 0.48, p = 0.00)

Diabetes Distress Screening Scale (DDSS)

Baseline End of

study p value

Emotional Burden 3.2 ± 1.4 3.0 ± 1.2 0.023*

Physician-related Distress 2.5 ± 1.2 2.0 ± 1.1 <0.001*

Regimen-related Distress 3.3 ± 1.2 2.9 ± 1.1 <0.001*

Interpersonal Distress 2.5 ± 1.3 2.3 ± 1.3 0.084

Total Score 2.9 ± 0.9 2.6 ± 0.9 <0.001*

Comparison of DDSS before and after DMNC intervention

Values are mean + standard deviation; * Significant difference with p < 0.05

Insulin Related Stress Score (IRSS)

Baseline End of study p value

Insulin needle 4.7 ± 3.6 2.4 ± 2.8 <0.001*

Injection Skill 4.6 ± 3.6 2.5 ± 2.8 <0.001*

Convenience 5.0 ± 3.5 2.8 ± 2.9 <0.001*

Discrimination 3.5 ± 3.6 1.9 ± 2.7 <0.001*

Indication for insulin therapy 5.0 ± 3.4 3.2 ± 2.9 <0.001*

Values are mean + standard deviation; * Significant difference with p < 0.05

Comparison of IRSS before and after DMNC intervention

Summary of Diabetes Self-Care Activities

(SDSCA)

Baseline End of study p value

General Diet 3.5 ± 2.5 4.3 ± 2.3 0.004* DM Specific Diet 3.6 ± 1.8 4.0 ± 1.9 0.020*

Exercise 3.3 ± 2.5 3.6 ± 2.4 0.126

Self-monitor of Blood Glucose 2.1 ± 2.5 3.0 ± 2.2 0.001* Foot Care 4.4 ± 2.0 4.6 ± 1.9 0.280

Anti-DM Drug Compliance 6.3 ± 1.9 6.5 ± 1.3 0.186 Hypoglycaemia management 1.6 ± 2.8 2.8 ± 3.3 <0.001*

Smoking 0.8 ± 0.4 0.8 ± 0.4 0.319

Values are mean + standard deviation; * Significant difference with p < 0.05

Comparison of SDSCA before and after DMNC intervention

Summary

Significant different with p < 0.05 HbA1c 10.1% -> 7.9% (↓2.2%)

Body weight ↑ Mean 0.861 kg Lipid profile Improved TG, LDL, HDL

DDSS Emotional Burden Physician-related Distress Regimen-related Distress

Total score IRSS Insulin needle

Injection skill Convenience

Discrimination Indication for insulin therapy

SDSCA General diet DM Diet

SMBG Hypo

Nurse-patient contact time

• Mean 147±66 minutes • Median 135 minutes 58.5% 105 - 165 minutes 3 – 4 consultation 17.7% 45 – 90 minutes less than 3 consultation 23.8% 180 minutes more than 4 consultation

Discussion

• Improved HbA1c and lipid profile • Decreased the psychological distress both diabetes stress and insulin

related stress • Enhanced the behavior modification on DM diet, self-monitoring

blood glucose and hypoglycemia management • Slight increased body weight after initiated insulin therapy • Varied contact time may be due to the complexity of treatment,

patient’s learning ability or different nursing practice

Conclusion

• DMNC is the effective intervention to manage patient who needs initiation of insulin therapy

• Should be recommended as the routine medical care • Explore the situations of varied contact time and standardization of

service provision in the different health care settings in future direction

Acknowledgement

First Author Ms. Elaine Leung, NC (DM) QMH Co-author Ms. Maisy Mok, NC (DM) KEC Ms. Annie Leung, NC (DM) YCH Member •DM nurses in QMH, UCH & YCH •Diabetes Service Development Committee (Sub-committee of SAG, Endocrinology) •SAG (Endocrinology)