C. HAGGETT, M. VALLIS, MJ. DUNBAR*, P. TALBOT

Diabetes Care Program of Nova Scotia (DCPNS), Halifax, NS, Canada Website: http://diabetescare.nshealth.ca/

Acknowledgement: We would like to acknowledge the guidance provided by the Behavior Change Institute, Nova Scotia as well as working group members Janice Knapp, Elizabeth Kingsland, Karen Marchand, Elizabeth Skelhorn, Brenda Sutherland, and Tina Witherall.

WHY AREN’T PATIENTS SELF-ADJUSTING INSULIN? THE PATIENT’S PERSPECTIVE (PART 2)

BACKGROUND

When patients managing their diabetes with insulin therapy are compared to patients managing their diabetes with non-insulin therapies (oral agents [OAAs]/injectables) or lifestyle only, people using insulin (In) therapy have more difficulty achieving glycemic targets.

FIGURE 1: A1C BY DIABETES TREATMENT CATEGORY (N = 10,088)

0%

20%

40%

60%

80%

100%

Lifestyle Only

Insulin (In)

OAA In/OAA Total

< 7% 7-8.49% 8.5- 8.99% ≥ 9%

PURPOSE The purpose of this project was:

!  To guide provincial work already underway (Part 1) aimed at improving glycemic management in insulin-treated individuals. To complement a provider survey, a patient survey was designed, with a focus on patient self-adjustment of insulin, to determine if/how they self-adjust insulin, when they adjust insulin, what helps/hinders self-adjustment of insulin, and the role stress may play.

!  To guide the development of standardized tools and resources to assist both providers and patients in assessing and addressing readiness and to facilitate patient self-adjustment of insulin.

METHODS

!  Adults with diabetes using insulin therapy for ≥ 6 months were surveyed over a 1-month period early in 2016 in 6 Nova Scotia Diabetes Centres.

Questions included: –   Demographics: age, gender, length of time on insulin, types of insulin, number of injections

–   Present practices related to self-adjustment of insulin: how often, reasons for adjustment, tools/resources used

–   Perceived barriers/enablers to self-adjustment of insulin, including the impact of stress

RESULTS

!  101 persons with diabetes completed the survey and agreed the information could be used in publication/presentation. 79 of 101 (78%) self-adjusted insulin: Male=44.3%; mean age 56.2. Compared to adjusters, non-adjusters (n=22) were older (mean age 68.4), 55% ≥ 70 years vs. 17.7%. FIGURE 2: MODERATE-SERIOUS PROBLEMS FOR PATIENTS (ADJUSTERS AND

NON-ADJUSTERS)

MODERATE-SERIOUS PROBLEMS FOR PATIENT:

!

ADJUSTERS (79)

NON-ADJUSTERS (22)

Fear of going low (hypoglycemia) 38.1% 46.7%

Expense of testing 27.4% 26.7%

Difficulty understanding how to adjust 23.3% 35.7%

Not confident to adjust properly 15.0% 33.3%

Diabetes Distress Screen: Feels that adjusting insulin

increases the stress of having diabetes 18.8% 25.0%

FACTORS THAT…HELP…MOST OF THE TIME/ALWAYS (N) & %

WHO SUPPORTS (ENCOURAGES YOU) (N) & %

!  Comfortable making adjustments (61) – 81%

!  Patient wants control of his/her diabetes (68) – 92%

!  Patient has support of MD/diabetes team (67) – 92%

!  Patient feels better when he/she adjusts own insulin (47) – 66%

!  Family members (23) – 30%

!  Friends (7) – 9%

!  MD/NP (42) – 55%

!  Diabetes team (55) – 71%

FIGURE 3: REPORTED FACTORS THAT HELP PATIENT SELF-ADJUSTMENT OF INSULIN AND WHO SUPPORTS (ENCOURAGES) SELF-ADJUSTMENT (ADJUSTERS N=79)

CONCLUSIONS

!  This study confirms the value of continued work on supportive tools and resources for both patients and providers, with an additional focus on older insulin users. It reinforced the earlier identified traits found in non-adjusters of poor understanding, fear of hypoglycemia, and lack of psychological readiness (Part 1, IDF 2015).

!  Diabetes distress/stress should be considered when working with insulin-using patients as it may play an initial and continuous role in self-adjustment of insulin.

!  The MD and the diabetes team are recognized to be instrumental in encouraging/supporting

patient self-adjustment of insulin. !  Tools in development include:

-  An algorithm to guide decisions related to patient ability/readiness to self-adjust.

-  Tools to assess (questionnaires) and then assist recommended approaches (short videos) to the specific readiness categories: a focus on comprehension/cognition, psychological insulin resistance, motivation, readiness to self-adjust, and fear of hypoglycemia.

-  Standardized insulin adjustment tools for patients.

[Type text] DCPNS Draft July 4,2016

DO YOU UNDERSTAND WHAT YOU HAVE BEEN ASKED TO DO WITH ADJUSTING YOUR INSULIN?

Develop Action Plan

Provide Tools /supports for adjusting: Handouts: • Instructions on How to Adjust Your Insulin • Part 1: Starting Insulin, 1 insulin Only • Part 2: When Starting Meal Time Insulin • Part 3: When on MDI (basal/bolus)

COMPLETE READINESS ASSESSM ENT

Reasons?

• Psychological insulin resistance (V & Q) • Fear of Hypoglycemia (V & Q) • Motivation • Comprehension / Cognition (V & Q)

• Discuss checklist • Pros and cons of self adjustment

of insulin • Discuss:

o Psychological Insulin resistance statements

o Fear of hypoglycemia o Motivation

Review Checklist for Insulin Self Adjustment • Checklist—What Does It Mean to Self-Adjust My

Insulin? NO

Review, clarify learning needs, educate as needed

Initiate readiness assessment when ready

Note: If not able to complete easily, • Perform cognitive assessment to evaluate

all levels of comprehension, Or • Notify Referring Provider

ACTION:

Inform provider re need for:

• Family, Home Care/VON supports • Family Dr. adjustment

Note: DC may be able to provide time-limited supports.

Is there a preparation and reassessment process for this patient?

Video (V) Support Series: • Benefits of self-adjustment • Fear of Hypoglycemia • Psychological Insulin Resistance • How to adjust insulin

Supporting Questionnaires: • Management of Fear • Montreal Cognitive Assessment • Psychological Insulin Resistance

Ask the questions below re psychological insulin resistance

Psychological Insulin Resistance Questions (Q)

Circle the way you feel:

• Insulin takes my freedom away • Being on insulin makes me feel like I failed • Insulin means my disease is more serious • Insulin is more work than it is worth • I am nervous about injections • I lack confidence in managing my diabetes using insulin • Is it important for you to make up your own mind? • Since no one asks for diabetes it is hard to care for it. But

since it is yours would you be willing to take control of it before it takes control of you?

YES NO, NOT READY

AMBIVALENT

FIGURE 4: ALGORITHM—READINESS ASSESSMENT

FIGURE 5: DRAFT SELF-ASSESSMENT: AM I READY TO ADJUST MY INSULIN?

SNEAK PREVIEW (TOOLS) RESULTS (CONT)

The Diabetes Care Program of Nova Scotia (DCPNS) was originally one of the Provincial Programs funded by the Nova Scotia (NS) Department of Health & Wellness. In April 2016, the DCPNS transferred to the Nova Scotia Health Authority (NSHA). Implemented in 1991, the DCPNS was initially mandated to standardize and improve the quality of care provided through Nova Scotia’s 38 Diabetes Centres. The DCPNS: • Advises on service delivery models  • Provides support, services, and resources to diabetes healthcare providers

• Establishes and monitors adherence to diabetes guidelines  • Collects, analyzes, and distributes diabetes data for NS

DCPNS mission: To improve, through leadership and partnerships, the health of Nova Scotians living with, affected by, or at risk of developing diabetes 19th Annual CDA/CSEM Professional Conference

Ottawa, Ontario, October 26-29, 2016

Draft DCPNS October 19, 2016

SELF-ASSESSMENT: AM I READY TO ADJUST MY INSULIN?

What Does It Mean to Self-Adjust My Insulin?

Self-adjustment of insulin means to assess your blood glucose and then take more or less insulin to reach or maintain your target blood glucose values.

Why would I want to adjust my own insulin?

Once you are using insulin to treat your diabetes, adjusting your own insulin will lead to:

• better control of your blood glucose, • fewer visits to your diabetes team/doctor to adjust your insulin, • more confidence, and • a recognition that you are the one most able to manage your blood glucose values.

What Do I Need to Know to Adjust My Own Insulin?

To safely self-adjust your insulin there are a number of things you need to know.

• Using the table below, place a ✔ in the column that best describes your understanding of each item.

Do you have a very good understanding or does it need some work? Remember, the diabetes team will work with you and support you as you learn to adjust your insulin.

MY UNDERSTANDING IS…

VERY GOOD

FAIR NEEDS SOME WORK

I understand the risks of high and low blood glucose

I understand how my insulin works (when it works, for how long, and which meals/snacks it covers)

I understand the importance of testing my blood glucose routinely (it could be 4-6 times a day) when adjusting my insulin dose

I understand what my blood glucose results mean (high, low, just right) AND what causes changes in my blood glucose (exercise, extra or less food, stress, alcohol, etc.)

I know my target blood glucose values:

• Before breakfast

• Before lunch

• Before supper

• At bedtime

I am able to follow simple guidelines for how much insulin to take and when to take it

I know when to seek advice from my doctor/diabetes team