Do interventions by allied health professionals discussing adherence to insulin improve this adherence?

Do interventions by allied health professionals discussing adherence to insulin improve this adherence?

DIAB-6032; No. of Pages 3 diabetes research and clinical practice xxx (2014) xxx.e1–xxx.e3 Contents available at ScienceDirect Diabetes Research and...

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DIAB-6032; No. of Pages 3 diabetes research and clinical practice xxx (2014) xxx.e1–xxx.e3

Contents available at ScienceDirect

Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres

Brief report

Do interventions by allied health professionals discussing adherence to insulin improve this adherence? S.A. Doggrell a,*, V. Chan b a School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Gardens Point, GPO 2434, Brisbane, QLD 4001, Australia b School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Gardens Point, GPO 2434, Brisbane, QLD 4001, Australia

article info

abstract

Article history:

It is assumed that interventions to improve the adherence to insulin by allied health

Received 19 April 2013

professionals discussing adherence to insulin will improve this adherence. However, there

Received in revised form

is little evidence to support this, as interventions by a pharmacist or nurse educator have not

7 March 2014

been shown conclusively to improve adherence to insulin.

Accepted 22 March 2014

# 2014 Elsevier Ireland Ltd. All rights reserved.

Available online xxx Keywords: Adherence Diabetes Health professionals Insulin Insulin pens

1.

Introduction

Nonadherence to insulin is associated with increased mortality and morbidity [1,2]. There have been few studies of the rates of adherence to insulin, but these studies show rates of nonadherence ranging from 20 to 80% [3–5], which indicates that adherence is a significant problem. It is well established that intervention or care by pharmacists/nurses/educators can improve HbA1c levels in subjects with diabetes [6]. However, this does not

necessarily mean there is improved adherence to insulin, as improvement of many other aspects of the management of diabetes can lead to improved HbA1c levels. We have reviewed the effect that an intervention by an allied health professional, which discusses adherence to insulin, has on adherence to insulin. Surprisingly to us, extensive searching of PubMed, CINAHL, PsycINFO, and Health and Medicine Complete for ‘insulin’ and ‘adherence’ (or associated terms) shows little evidence that such interventions do improve the adherence.

* Corresponding author. Tel.: +61 7 3138 2015; fax: +61 7 3138 1534. E-mail address: [email protected] (S.A. Doggrell). http://dx.doi.org/10.1016/j.diabres.2014.03.014 0168-8227/# 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: Doggrell SA, Chan V, Do interventions by allied health professionals discussing adherence to insulin improve this adherence?. Diabetes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.diabres.2014.03.014

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2. Interventions by a pharmacist to improve adherence There have been many articles which suggest that intervention/education by a pharmacist is likely to improve adherence to insulin (e.g. [7,8]). However, we were unable to find any evidence that an intervention by a pharmacist, which discusses adherence to insulin, does actually improve the measured adherence to insulin.

3. Interventions by nurse/educator to improve adherence Our searching of the literature showed limited and variable evidence that an intervention by a nurse/educator that discusses adherence to insulin does improve this adherence. In a small study, where 27 low-income subjects with poorly managed Type 2 diabetes (HbA1c of 10.8%, 95 mmol/mol) were being allocated insulin for the first time, and both a general physician and a diabetes nurse educator was involved in their education, 40% of the 27 were nonadherent to insulin at 3 months [9]. This study has no control group, and there is a high rate of nonadherence, and suggests that the extra involvement of the general physician and diabetes nurse educator had little effect. In 2010, reciprocal peer support versus nurse care management was compared in 244 veterans with Type 2 diabetes and poor glycaemic control [10]. At baseline, about 73% of subjects reported missing insulin doses, and this was not improved after 6 months by reciprocal peer support or nurse care management [10]. However, after 6 months, there was a reduction in HbA1c from 8.02 to 7.73% (64–61 mmol/mol) in the reciprocal support group, compared to an increase from 7.93 to 8.22% (63–66 mmol/mol) in the nurse management group [10], which was not due to improved adherence. In the 2011, Improving Diabetes Outcomes study, 526 lowincome participants with Type 2 diabetes, of which only 24% were taking insulin were enrolled [11]. It was shown that telephone calls by a health educator, trained by certified diabetes educator nurse, compared to print information, increased adherence to oral anti-diabetic drugs and glycaemic control, but not adherence to insulin [11]. In a 2012 pilot study of 10 adults with Type 1 diabetes and depression, it was shown that an intervention that offered 2 visits with a certified diabetes nurse educator, 3 visits with a registered dietician, and 10–12 sessions of cognitive-behavioural therapy for adherence and depression improved adherence in the 7 subjects who completed [12]. Adherence was self-report of how often they took their insulin, and increased from 77% before to 87% after the intervention, and a modest decrease in HbA1c from 9.6% (81 mmol/mol) to 9.0% (75 mmol/mol) [12]. There are several problems with this study including the lack of a control group, low numbers of subjects, and high self-reported adherence. The OPENING (Organization Program of DiabEtes INsulIn ManaGement) study, performed at 48 centres throughout China, used trained nurses to deliver an education program to subjects with Type 2 diabetes [13]. In this study, 1511 subjects

with inadequate responses to two or more oral anti-diabetic medicines were started on the same insulin therapy, which was adjusted according to the subjects’ pre-meal glucose levels [13]. The control group had normal care, and the education group additional education, where the nurse educator delivered a structured education program with seven components: taking medication, insulin injection technique, self-monitoring of blood glucose, healthy diet, physical activity, prevention of hypoglycaemia, and prevention of complications [13]. In addition, in the education group, a short message was sent 2–3 days before the visits that occurred in weeks 0, 2, 4, 8, 12, and 16, and the message reminded subjects about injecting insulin at the right time, performing self-monitoring of blood glucose, and when their appointment was [13]. At baseline, adherence was similar in both groups, and the adherence to insulin was improved by the education [13]. However, this improvement in adherence was only associated with a small benefit in glycaemic control (0.16%) [13]. Thus, in the control group, the baseline HbA1c was 9.46% (80 mmol/mol) and this was reduced to 7.38% (54 mmol/ mol) by the start of insulin with normal care, whereas in the education group, the HbA1c was reduced from 9.38% (79 mmol/mol) to 7.22% (55 mmol/mol) [13].

4.

Conclusions

There is no conclusive evidence that an intervention by a health professional that discusses adherence to insulin actually improves adherence to insulin. For pharmacists, there is no evidence. For nurse/educators, this is some evidence that an intervention, which discusses adherence to insulin may improve this adherence, but this is not found in all studies. Rather than assuming that this is the case, longterm studies investigating whether adherence to insulin can be improved by interventions by health professions by discussing this, are required.

Conflict of interest The authors have no conflicts of interest.

references

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Please cite this article in press as: Doggrell SA, Chan V, Do interventions by allied health professionals discussing adherence to insulin improve this adherence?. Diabetes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.diabres.2014.03.014

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[4] Olinder AL, Kernell A, Smide B. Missed bolus doses: devastating for metabolic control in CSII-treated adolescents with type 1 diabetes. Pediatr Diabetes 2009;10:142–8. [5] Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care 2004;27:1218–24. [6] Davidson MB. The effectiveness of nurse- and pharmacistdirected care in diabetes disease management: a narrative review. Curr Diabetes Rev 2007;3:280–6. [7] Vivian EM. The pharmacist’s role in maintaining adherence to insulin therapy in type 2 diabetes mellitus. Consult Pharm 2007;22:320–32. [8] Grossman S. Management of type 2 diabetes mellitus in the elderly: role of the pharmacist in multidisciplinary health care team. J Multidiscip Healthc 2011;4:149–54. [9] Lerman I, Dı´az JPM, Ibarguengoitia MER, Perez FJ, Villa AR, Velasco M, et al. Nonadherence to insulin therapy in lowincome, type 2 diabetic patients. Endocr Pract 2009;15:41–6.

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[10] Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal support versus nurse care management – a randomized trial. Ann Intern Med 2010;153:507–15. [11] Walker EA, Blanco E, Shmukler C, Blanco E, ScollanKoliopoulus M, Cohen MW. Results of a successful telephonic intervention to improve diabetic control in urban adults – a randomised trial. Diabetes Care 2011; 34:2–7. [12] Markowitz SM, Carper MM, Gonzalez JS, Delahanty LM, Safren SA. Cognitive-behavioral therapy for the treatment of depression and adherence in patients with type 1 diabetes: pilot data and feasibility. Prim Care Companion CNS Disord 2012;1:4. http://dx.doi.org/10.4088/ PCC.11m012220. [13] Guo XH, Ji LN, Lu JM, Liu J, Lou QQ, Liu J, et al. Efficacy of structured education in patients with type 2 diabetes mellitus receiving insulin treatment. J Diabetes 2013. http:// dx.doi.org/10.1111/1753-0407.12100.

Please cite this article in press as: Doggrell SA, Chan V, Do interventions by allied health professionals discussing adherence to insulin improve this adherence?. Diabetes Res Clin Pract (2014), http://dx.doi.org/10.1016/j.diabres.2014.03.014