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Barriers, solutions to insulin injection therapy for type 2 diabetes

Issue: February 2013

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Many advances have been made in diabetes that include the introduction of highly successful therapies and tools, such as more effective medications, blood glucose meters, insulin delivery systems and needle size. Yet, despite all of this progress, patients can still have challenges in meeting target treatment goals. Barriers to initiating and adhering to insulin injection therapy include a wide range of obstacles relating to patients, providers and health care systems. Identifying these barriers, as well as possible solutions to overcome them, is a critical step toward successful diabetes self-management.

Linda Siminerio

Common barriers to insulin therapy

These are some frequently reported barriers:

• Clinical inertia: Clinicians can play a significant role in ensuring the success of diabetes treatment plans. Unfortunately, many clinicians are unable to translate identification of high-risk factors associated with diabetes to appropriate therapeutic management and effective metabolic control. Clinician failure to intensify management has been referred to as “clinical inertia.” Clinical inertia and delayed intensive management can be attributed to many factors. Diabetes is a complex disease that requires patients to be knowledgeable and able to make daily decisions that affect their health. The complexity of diabetes management requires that health care providers support their patients with the appropriate amount of time, education and long-term care that are necessary for effective self-management and adherence. Most patients with type 2 diabetes are seen in a primary care setting, which presents challenges in overcoming clinical inertia and facilitation of intensified therapies. A provider’s decision to delay therapy in many cases may be related to time constraints, limited educational resources and added workload.
• Psychological insulin resistance has been reported in both physicians and patients whose earlier experiences with longer, wider gauge needles used for antibiotics and veni-punctures, for example, have caused misperceptions and reluctance to prescribe and accept insulin. Patient willingness to use injectable therapies and adherence are also important considerations. In a survey by Davidson et al, when patients were asked about their willingness to take injections, results indicated that 46% would avoid taking insulin, 41% would accept insulin when a physician recommends it and 13% would be apprehensive about using insulin, even if recommended by a physician.
• Resistance by physicians to prescribe insulin therapy is often based on their perceptions of patient-derived barriers, such as concerns about the patient’s weight, adherence behavior and desire to prolong non-insulin therapy. Interestingly, a survey shows that most primary care physicians in the United States report that patients feel much better after starting insulin therapy and are able to manage the demands of the regimen.
• Adherence to treatment: Adhering to a rigorous routine of diabetes management can be challenging. Although the data on patient adherence in patients with type 2 diabetes are somewhat limited — especially when considering insulin-taking behaviors — the average adherence rate for oral medications for type 2 diabetes tends to fall in the 65% to 85% range. In some populations, adherence is only 36% to 54%. Reasons for poor adherence include patients forgetting, fear, incomplete instructions, multiple and complex regimens, concerns about side effects, disappointment with symptom relief and costs. Concerns that insulin therapy will be complicated and inconvenient, as well anxieties about pain and needles, are also common.
• Financial limitations: A financial barrier exists for patients who lack insurance coverage for certain supplies, such as insulin pens. However, pharmacoeconomic data reveal cost benefits for using delivery systems such as pens. For example, studies have shown that when patients use pens vs. syringes there are cost savings associated with improved treatment adherence and reduced health care utilization. Additionally, in some cases, the individual with coverage for insulin pens may only have one co-pay, resulting in getting more insulin per co-pay than if purchasing a vial. For those who use smaller doses of insulin, the disposable insulin pens with 3-mL cartridges can be more economical. Promulgation of these findings could drive changes in reimbursement policies.
• Health care systems: Limitations in health care systems also create barriers to insulin injection therapy. The Diabetes Attitudes, Wishes and Needs (DAWN) study found that nurses and physicians think more involvement by nurses is needed to support diabetes care. The investigators emphasized that inadequate insulin therapy education among nurses and PCPs can be a significant obstacle to insulin initiation, necessitating more training in insulin injection technique for nurses, more titration protocols for use by non-physician practitioners, and increased support to PCPs. Concerns about time constraints often delay therapy initiation. Data indicating that among community hospital nurses, patient instruction took less than 15 minutes for insulin pen use and 16 to 30 minutes for conventional method use make consideration of pen use a viable option.

Conquering concerns and overcoming barriers

Despite these barriers, here are steps and solutions that can be implemented to help overcome these challenges:

• New injection therapy technology: New delivery devices and tools, such as insulin pens and refined, shorter needles, are being introduced to provide ease, limit pain and to help overcome many of the barriers to injections. A 4-mm, 32-gauge pen needle, for example, has been shown to provide equivalent glycemic control compared with 31-gauge, 5-mm and 8-mm pen needles with reduced pain, no difference in insulin leakage and was preferred by patients.
• Continuous improvements: Novel approaches to engage physicians and patients must be explored. It has been shown that traditional mechanisms of providing physician education alone are not as effective in improving practice and patient behavior as systems change. Modern understanding of diabetes management advocates for the superiority of team care and community-based approaches. The patient-centered medical home, which incorporates team-based care and community resources, is being implemented in a number of health care practices in the United States, with widespread enthusiasm. To overcome the barriers to better diabetes outcomes while improving the balance between education and pharmacotherapy, novel approaches must be examined when introducing new therapies and tools into practice.
• Sufficient education: Educational resources are paramount to ensuring proper self-care and treatment adherence. Patient education sessions and materials should be comprehensive and available to address a variety of patient concerns about insulin therapy. Early in the education process, patients should be taught how to recognize, treat and avoid hypoglycemia. Such education, including the importance of meal planning, is imperative. Some educational strategies for lessening fear of needles include use of a pillow for trial injections, use of a covered safety needle to conceal the needle, and the practice of desensitization, whereby the needle is placed on the patient’s skin and allowed to remain there momentarily before injecting.
• To help patients overcome resistance that may result from myths and misconceptions — such as the belief that the need for insulin reflects personal failure — practitioners can especially help diminish self-blame by explaining at the time of diagnosis that type 2 diabetes is a progressive deterioration of beta-cell function, and insulin will likely be required at some point.
• Calling attention to these barriers and solutions for diabetes treatment is intended to improve diabetes outcomes by providing access to education and helping overcome obstacles to insulin injection therapy. With a robust approach to helping diabetes patients engage in effective treatment plans, we can collectively help to improve patient outcomes.