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Choice of insulins, pen devices and blood glucose meters: factors influencing decision making by DSNs in the UK AD Thynne*, B Higgins, MH Cummings Introduction In the UK, it is recognised that DSNs have a pivotal and often autonomous role in initiating insulin therapy. Most patients with diabetes requiring insulin use an insulin pen device and blood glucose meter (BGM) to optimise glycaemic control. There are no clear guidelines on how DSNs in collaboration with patients derive the final combination of insulin type, pen device and BGM. Therefore, the primary aim of this study was to identify which factors influence the thought processes of the DSN when they are deciding which insulin type, pen device and blood glucose meter is suitable for their patient. In the current market there are at least 30 different insulin types, 10 pen devices and 11 BGMs. Assuming that the vast production and diversity of insulin therapy equipment has a place in the diabetes market, a secondary aim was to examine whether their various specific features and standard functions have an important role in affecting choice. Acknowledging the move toward encouraging patient empowerment we also aimed to explore the relative contribution of the DSN and patient in determining the appropriate insulin type and associated equipment for an individual. To ensure all variables were considered, our tertiary aim was to examine whether there were any trends in responses according to Anita D Thynne, BSc (Hons), RGN, PGCE, Diabetes Specialist Nurse, Department of Diabetes and Endocrinology Bernie Higgins, PgD, MRSS, Senior Lecturer in Statistics, RDSU, School of Postgraduate Medicine Michael H Cummings, MD, FRCP,
Pract Diab Int September 2003 Vol. 20 No. 7
ABSTRACT Choices of insulin type and associated equipment largely result from discussions between patients and diabetes specialist nurses (DSNs), although we clearly do not fully understand the process leading to decision making. To establish a greater understanding of prescribing issues, we developed a UK questionnaire designed to identify factors influencing choice and the importance of the DSN’s role. Furthermore, trends in responses according to experience of the DSN and geographical location of the practice were also examined. A Likert scale was employed where 1 = strongly disagree, 2 = disagree, 3 = agree and 4 = strongly agree. Insulin therapy was independently initiated by 96 per cent of DSNs. DSNs were likely to choose the insulin type (mean score 2.84) whereas patients were likely to choose pen devices (mean score 2.81). The DSN and patient were equally involved in choosing blood glucose meters (BGMs) (mean scores both 2.41). Key influential factors (mean score >3) when choosing insulin types were previous experience of the DSN and literature product availability. Influential factors when choosing pen devices (mean score >3) were accuracy, cartridge loading and reliability (pen features) and poor learning ability, poor memory and impaired sight (patient characteristics). Principle factors influencing choice of BGMs (mean score >3) were display size, accuracy and reliability (meter features) and impaired sight, poor dexterity and poor memory (patient characteristics). We conclude that both DSN and patient were integrally involved in decision making and there are heterogeneous complex factors influencing these choices. There were no trends in choice with regard to geographical location of the diabetes service or duration of DSN experience. Copyright © 2003 John Wiley & Sons, Ltd. Practical Diabetes Int 2003; 20(7): 237–242
KEY WORDS insulin type; pen devices; blood glucose meters; influencing factors; decision making; choice
the level of experience of the DSN, recognising that management of diabetes is an ongoing changeable process. Geographical location was also considered, since we were aware that local policies and resources may influence decision making. When designing this study, we acknowledged that the role of DSNs in choosing and providing patients with insulin provoked discussions around the legal implications of nurse prescribing. However, the aim of this study was to investigate the
intellectual decision making process of the DSN and not the prescribing issues per se.
Participants and methods An anonymous postal questionnaire was devised using a Likert Scale design to identify factors influencing DSNs decision making when choosing an insulin type, pen device and BGM. For the majority of questions, DSNs were asked to respond by indicating whether they strongly agreed, agreed, disagreed or strongly disagreed with the state-
Consultant Physician, Department of Diabetes and Endocrinology Queen Alexandra Hospital, Cosham, Portsmouth
Endocrinology, Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire PO6 3LY, UK; e-mail:
[email protected]
*Correspondence to: Anita Thynne, Department of Diabetes and
Received: 20 December 2002 Accepted: 16 June 2003
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Table 1. Demographics of diabetes specialist nurses (DSNs) responding to the questionnaire (n=227)
No. of DSNs
Percentage
70 27 12 10 4 53 51
30.8 11.9 5.3 4.4 1.8 23.3 22.5
58 87 48 34
25.6 38.3 21.1 15
217/226
95.6
Geographical location Southern England Scotland Wales Northern Ireland Eire Midlands Northern England
Years practising 0–5 6–10 11–15 16 or more
Initiate insulin therapy Yes
ment (equating to scores of 4, 3, 2 or 1 respectively). There was also opportunity for nurses to express their responses to a proportion of questions qualitatively. The following areas were considered to be potential influences in the decision making process and so determined the questions set: • Relative influence of DSN and
patient in the role of decision making • Availability and stock of insulin type, pen devices and BGMs within diabetes centres and hospital pharmacies • Pharmacological factors and manufacture of insulin type • Particular features of a given pen device or BGM
Figure 1. Diabetes specialist nurses’ (DSNs’) beliefs
Clinic time was inadequate to give choice of BGM Clinic time was inadequate to give choice of pen device Clinic time was adequate to give choice of insulin DSN’s personal preference would not influence choice of blood glucose meter DSN’s personal preference would not influence choice of pen device DSNs and patients equally choose BGMs Patients chose pen devices DSNs chose insulin type
0
1
2 Mean score
3
4
Key: 4 = strongly agree, 3 = agree, 2=disagree, 1 = strongly disagree
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• Costs of insulin therapy equipment • Local policies • Pharmaceutical support. Participants were selected from the Diabetes UK DSN Directory 2001. A single questionnaire was sent to each diabetes centre to ensure a representative view of care policies throughout the UK, thereby avoiding bias from large departments. A total of 433 questionnaires were distributed in the latter part of 2001 with a standard letter and reply-paid envelope. Of these, 227 responses (52.4% response rate) were received and analysed two months after distribution. Scores were entered onto a Microsoft Excel spreadsheet and exported to SCSS (Statistical Package for Social Sciences). Descriptive statistical analyses are presented and trends in multiple variables were examined by analysis of variance. For the purpose of statistical analysis, responses were divided into three sections: section one focussed on insulin type, section two on pen devices and section three on BGMs. In order to analyse trends in geographical location, we arbitrarily divided the UK into seven areas as follows: Southern England, Scotland, Wales, Northern Ireland, Eire, Midlands and Northern England. Trends relating to duration of experience were examined according to whether the nurse has practised as a DSN for 0–5 years, 6–10 years, 11–15 years or 16 or more years.
Results Demographic details of the 227 respondents are shown in Table 1. The largest response rate was from Southern England and the greatest number of respondents had been practising for 6–10 years. Only nine DSNs (4.0%) did not autonomously initiate insulin therapy. DSNs felt they predominantly chose the insulin type. Conversely, DSNs felt patients more often chose the pen device. Patients and DSNs had equal influence over choice of BGMs. DSNs who chose equipment on behalf of their patient felt that personal preference for a particular pen device or BGM would not pro-
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Figure 2a. Insulin stock within diabetes centres and hospital pharmacies
Figure 2b. Stock of re-usable pen devices and disposable pen devices within diabetes centres
Diabetes centres
0
20
40 60 Per cent
Blood glucose meters
Reusable pen devices
80
Figure 2c. Stock of blood glucose meters within diabetes centres
100 0
20
40 60 Per cent
80
100 0
Hospital pharmacies
20
Disposable pen devices
40 60 Per cent
80
100
Roche Diagnostics Medisense Lifescan 0
20
40 60 Per cent
80
DiagnoSys Medical
100
Novo Nordisk Eli Lilly CP Pharmaceuticals Aventis
foundly influence choice. Mean scores indicated that pen devices were more often chosen prior to the insulin type (3.04) rather than choice of insulin followed by the pen device (2.72). Most DSNs agreed clinic time was adequate to provide a choice of insulin but were less content with time allocated for demonstration of pen devices and BGMs (Figure 1). Patient literature explaining insulin types were stocked within most centres (88%), as was literature on pen devices (94%) and BGMs (92%). Figures 2a, 2b and 2c show availability of insulin, pen devices and BGMs within diabetes centres and hospital pharmacies. Eli Lilly and Novo Nordisk insulin and pen devices were stocked in most diabetes centres. By contrast, availability of Aventis and CP Pharmaceuticals insulins were meagre, as were Becton Dickinson reusable pen devices and all other disposable pen devices. Over 90% of diabetes centres stocked both Medisense and Roche Diagnosic BGMs. By comparison, DiagnoSys Medical meters were only stocked in
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0
20
40 60 Per cent
80
Bayer
100
A Menarini
Owen Mumford Novo Nordisk Eli Lilly Becton Dickinson Aventis
20% of centres. Mean scores indicated that DSNs were ambivalent about whether they would alter their insulin of choice if it were not immediately available from stock (2.46). DSNs would, however, change their first choice of pen device (3.12) and BGM (3.16) if it were not in stock. DSNs were divided in their opinion on giving patients a choice of their complete pen device stock (2.39) and this was even less likely for BGM (2.13). DSNs disagreed that they do not give patients any choice of pen device (1.60) or BGM (1.73). Most DSNs agreed that personal experience of a given insulin type would affect future choice. Pharmaceutical production of a particular insulin type, local prescribing policies and pharmaceutical representative support, have a modest influence over choice whereas insulin and equipment costs are least likely to influence choice (Figure 3). Figure 4 shows factors relating to patient characteristics that signifi-
cantly influence DSN decisions to choose pen devices or BGMs. Factors such as impaired sight, poor dexterity, poor learning ability, and poor memory were largely equally influential although patients’ understanding of the English language was less of a discriminator for pen device choice but more influential in choice of BGM. Figures 5a and 5b show DSN ratings on which equipment features influence the pen device and BGM offered to patients. For pen devices, significant influential factors in descending order of mean scores >3 were: perceived accuracy, cartridge loading, perceived reliability, plunger reset, immediate availability, previous experience and dialling mechanism. For BGMs, size of display, perceived accuracy, perceived reliability, ease of fingerpricker, sensor strip insertion, immediate availability and previous experience were influential in choice. Factors such as aesthetics, special features, costs, policies and pharmaceutical representative support were seen as relatively unimportant when choosing both pen device and BGM (Figures 5a and 5b). There was no strong indication of priority when considering the
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Figure 3. Factors influencing choice of insulin type
0
1
2 3 Mean score
the diabetes service or duration of experience as a DSN.
4
Previous experience Literature Type of insulin Local policies Rep support Availability Cost Key: 4 = strongly agree, 3 = agree, 2=disagree, 1 = strongly disagree
order of importance in determining the choice of an insulin type, pen device and BGM. DSNs rated the decision to choose an insulin type as the most influential (mean score 2.41), followed by choosing the pen device (mean score 2.27) and lastly choosing the BGM (mean score 1.47). There were no clear trends in choice of insulin or equipment with regard to geographical location of
Discussion The novel findings of this study are the identification at a national level of a wide range of biomedical and human factors that interplay and determine the ultimate choice of insulin and associated equipment. Our data support the concept that there is no universal policy that can be employed to encompass the multiplicity of factors utilised in such decision making. We have identified a number of important principles that help guide health care professionals in the process of initiating insulin, pen devices and BGMs. Our study demonstrates the variable contribution of the DSN and patient in the decision making process. Finally the experience of the DSN or location of their practice within the UK did not seem to influence our findings. Although many factors were identified to be influential in decision making, previous experience, perceived reliability and accuracy of pens and BGMs were the most consistent reasons for DSN choice. Experience may reflect feedback to a given device from a patient, other health care professional or direct experience of the DSN. DSNs con-
Figure 4. Patient factors influencing choice of pen device and blood glucose meter offered Patient factors influencing choice of pen device offered
Mean scores
Patient factors influencing choice of blood glucose meter offered 3.4 3.3 3.2 3.1 3.0 2.9 2.8 2.7 2.6 Impaired sight
Poor Poor learning dexterity ability
Poor Understanding memory of English
Key: 4 = strongly agree, 3 = agree, 2=disagree, 1 = strongly disagree
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firmed that stocked equipment and insulin was used more frequently than that not stocked. This reflects the need for the DSN in most cases to give patients the insulin or associated equipment at the time of consultation. Those factors deemed influential in deciding upon equipment were fundamentally practical issues (see Figure 5a and b). The assumption is that the DSN uses expert knowledge to make decisions based upon the patient’s characteristics to ensure they can competently choose and utilise the devices. Similarly, other factors that played a significant role in decision making included safety issues, such as reliability, which we intuitively believe relate to the DSNs’ professional accountability. Consultation time was not a significant influence, since the majority of DSNs believed they had enough time to discuss insulin choice. In addition, costs did not influence choices of insulin, pen device or BGM, nor did aesthetics (Figure 5a and b). Costs may not be influential because the majority of diabetes centres and patients do not buy their equipment or consumables (sensor strips are of similar cost on prescription) and insulin costs are relatively similar. However, local policies determining the exclusive use of an insulin may reduce overall costs and so would be influential in a minority of cases. Appearance of equipment was found not to be influential, this may be because DSNs undertook this study, whereas a patient perspective may emphasise more the aesthetic appeal of the pen device or BGM. Although literature was deemed important, it is not known whether this is primarily because it is believed to be beneficial to the patient or whether it is because the pharmaceutical representatives supply it free of charge. There were no significant trends in geographical location of the practice although there were different methods of working across the UK with prescriptive policies and contracts with meter companies evident in some diabetes centres. Similarly, the number of years of
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practise did not produce any trends, which may be due to a number of factors involving DSN and health care professional training, evidence-based care and up-to-date personal development. Qualitative data supported the need for DSNs to choose the insulin on behalf of the patient. The DSN commonly stated that people newly diagnosed with type 1 diabetes are often too shocked to make decisions on the most appropriate insulin type. DSNs felt similarly about elderly patients. DSNs expressed that they were expert on the pharmacology of insulin and its suitability for certain lifestyles, and patients may be unaware of how these issues inter-relate especially if new to insulin. Patients tending to choose their own insulin were more likely to have long-standing type 2 diabetes and would be converting to insulin in a controlled and timely manner. DSNs often chose the pen device on behalf of the patient if they were newly diagnosed with type 1 diabetes or an elderly person with type 2 diabetes. DSNs felt that the latter group may become confused with a variety of pen devices, whereas the former group were often thought to be anxious and therefore unable to fully absorb the differences between equipment types. Decisions regarding BGM choice seemed to be changeable depending upon the patient’s characteristics and lifestyle, often jointly discussed between patient and DSN. Replies also indicated that pen devices are relatively uncomplicated in that they all result in the same end-point, i.e. the administration of insulin. Therefore patient selection of a pen device was considered to be relatively straightforward. By comparison, BGMs were considered by the DSN to be more complex with particular features, which may not be appropriate for all patients. For example, a meter able to test for ketones is not usually necessary for a person who has type 2 diabetes. These replies may explain why patients more frequently chose pen devices but DSNs and patients were equally involved in choosing
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Figure 5a. Factors influencing choice of pen device offered
0
1
2 Mean score
3
4
Key: 4 = strongly agree, 3 = agree, 2=disagree, 1 = strongly disagree
Accuracy Cartridge loading Reliability Plunger reset Availability Previous experience Dial mechanism Special features Rep support Demo time Local policies Aesthetics Costs
Figure 5b. Factors influencing choice of blood glucose meter offered Display size Accuracy Reliability Ease of fingerpricker Sensor strip insertion Availability Previous experience Sensor strip packaging Rep support 0
1
2
3
4
Mean score
Memory Special features Demo time
Key: 4 = strongly agree, 3 = agree, 2=disagree, 1 = strongly disagree
BGMs as the latter requires more guidance. To ‘empower’ indicates a shift in emphasis from the traditional medical model to a more patient-centred approach, which is particularly apt for people with diabetes.1 Health care professionals should recognise this to enable the patient to have enough knowledge to make informed choices about their actions and activities.1 Patients do, however, vary in their desire for involvement in decision making in consultations, which depends upon their perception of the problem. It has been found that those with
Local policies Aesthetics Costs
physical problems associated with chronic ill health and people over 61 years of age want a directed approach while younger patients have a greater overall desire for discussion.2,3 Younger patients seem to want reassurance of certainty or avoidance of the responsibility of a poor outcome.3,4 For these reasons it may be considered acceptable for DSNs to choose equipment on behalf of their patients if they use effective communication skills and engage in discussion during consultations, together with knowledge of their patients, to determine at which times and at which level their
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Key points • Choice of insulin, pen device and blood glucose meter is important • Heterogeneous and complex biochemical and human factors influence choice • To cater for patients’ individual needs, a wide variety of therapy options are required • Prescriptive protocols and pharmaceutical contracts may not be appropriate • The level of patient participation varies in diabetes specialist nurse consultations
patient wishes to be involved in decision making.3-5 Joint decision making between the patient and health care professional is preferred when more than one effective treatment exists. There will always be some imbalance, however, since the patient may well be unwell and vulnerable while the health care professional has the expert knowledge.4,5 In response to frequently being asked by patients to assist when choosing suitable BGMs, Diabetes UK have developed a health care professional-based questionnaire to identify which factors influence our guidance.6 In view of the above observations, it seems justified that the DSN respondents in this study identified that they make an expert clinical decision on whether the patient is given full choice, part choice or no choice in the insulin therapy equipment they will be given. Unfortunately, contrary to Golin et al.2 and McKinstry’s3 findings, the present study indicates that DSNs are not giving newly diagnosed type 1 diabetic patients (who are usually the younger age group) choice of therapy equipment. The consensus throughout the study, however, was that DSNs favoured discussion about patient lifestyle and needs before decisions were made, which would be consistent with findings from previous studies.3-5,7 There are three main limitations to this study. Firstly, response rate was modest at 52.4% and the
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comparatively large number of replies from Southern England may be considered to produce some bias in the results. Intuitively, however, it is believed that practice is unlikely to vary significantly from one region to another (as identified in our study) and so this sample size is likely to be representative of the UK. Secondly, since this study is cross-sectional it does not examine trends in prescribing issues. Pharmaceutical companies influence choices offered to patients simply because of economics that limit the products they manufacture and the associated marketing strategies. In the future, products may differ greatly, for instance, with the availability of inhaled insulin, noninvasive blood glucose monitoring and alternative devices for administering insulin. Increasing numbers of people being diagnosed with diabetes may also affect economic strategies and there are already moves by pharmaceutical companies towards withdrawing certain diabetes-related products that are currently free of charge from centres where DSNs practice. Some devices are becoming less accessible, which will further influence the choice offered to patients as highlighted in our study. A longitudinal study would facilitate the identification of trends over time. Lastly, this study collated data from DSNs’ interpretations of patient perspectives and therefore a further questionnaire may be appropriate to directly identify patients’ views. In addition, increasing ease of access and use of information technology will no doubt lead to increased patient awareness of their disease management and insulin therapy equipment on offer. Patients are then likely to be more influential in the type of insulin or equipment they believe will be beneficial to them, increasing individualised patient choice and decision making. A patient-directed study might prove to highlight very different factors influencing choice to those perceived by the DSN. As only 4% (nine centres) of DSNs did not have an autonomous role in initiating
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insulin, the role of doctors in these nine diabetes centres was not addressed. However, all doctors have direct and indirect control over choice as they directly recommend or prescribe insulin for patients and are influential in whether the insulin type or the equipment is prescribed in primary care or put on the hospital formulary. In conclusion, because of the many factors DSNs take into consideration when choosing insulin type and equipment with and on behalf of their patient, choice is important. One insulin type, pen device or blood glucose meter would not be sufficient for all individuals or suit their lifestyles. Thus a wide varieties of therapy options are needed, appropriate for the consumer market. Patient participation in decision making has been shown to depend upon DSN beliefs surrounding patient diagnosis, age, physical and cognitive function in relation to ability. As choice is so important to ensure the most suitable therapy equipment is give to the patient, we question whether prescriptive protocols and pharmaceutical contracts are appropriate.
References 1. Walker R. Diabetes: reflecting on empowerment. Nursing Standard 1998; 12(23): 49–56 2. Golin CE, DiMatteo MR, Leake B, et al. A Diabetes-specific measure of patient desire to participate in medical decision making. The Diabetes Educator 2001; 27(6): 875–886. 3. McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ 2000; 321: 867–871. 4. Alexander C. Influencing decision making. Nursing Standard 1997; 11(38): 39–44. 5. Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med 1998; 47(3): 329–339. 6. Diabetes UK. Choosing a blood glucose meter. Healthcare professionals questionnaire. Diabetes Update Spring 2002; 18–19. 7. Golin CE, DiMatteo MR, Gelberg L. The role of patient participations in the doctor visit. Implications for adherence to diabetes care. Diabetes Care 1996; 19(10): 1153–1164.
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