'Didn't See the Need': Misperceptions about glucagon from the perspectives of people with diabetes and their caregivers.

AIMS: Severe hypoglycaemia among people with diabetes who use insulin can be a life-threatening complication if left untreated. Although glucagon has been approved for treatment of hypoglycaemia since the 1960s, it has been underutilized. We aimed to understand the perceptions of people with diabetes and their caregivers about glucagon. METHODS: We conducted in-depth, one-on-one telephone interviews with people with diabetes and their caregivers in the United States. The interviews included questions around general awareness of glucagon, reasons for owning or not owning glucagon, and suggestions for improving understanding of glucagon as treatment for severe hypoglycaemia. Initial synopsis and inductive codebook schema were used to analyse the responses by two independent researchers. Themes were developed from the codes, and codes were re-mapped back to the themes. RESULTS: There were 60 dyads of people with diabetes and their caregivers (N = 120). Four themes developed from the interviews: (1) for most participants, the stated reasons for not owning or renewing a prescription for glucagon included unawareness of the medication, its advantages and its value; (2) misperceptions about glucagon occurred frequently; (3) caregivers often lacked confidence in administering reconstituted injectable glucagon; and (4) education and training from healthcare providers about glucagon would be welcomed. CONCLUSIONS: This study emphasizes the need for healthcare providers to discuss hypoglycaemia prevention and events at each clinical visit, including the use of glucagon in the case of severe hypoglycaemia. Healthcare providers are encouraged to assess the knowledge of people with diabetes and their caregivers regarding treatment and prevention of hypoglycaemia.

Population Health: The Diabetes Educator's Evolving Role.

PURPOSE: The US health care system's focus on high-quality, efficient, and cost-effective care has led payers and provider groups to identify new models with a shift toward value-based care. This perspective on clinical practice describes the population health movement and the opportunities for diabetes educators beyond diabetes self-management education, as well as steps to engage in and drive new care models to demonstrate individual, organizational, and payer value. CONCLUSION: Diabetes educators have an opportunity to position themselves as diabetes specialists for diabetes management, education, and population health care delivery. With expertise that extends beyond diabetes self-management education and with a wide variety of skills, diabetes educators recognize that there is a range of personal, social, economic, and environmental factors that influence diabetes health outcomes. Diabetes educators should align with organizational strategic plans and support the population-level performance measures and quality initiatives, thus enhancing the value that diabetes educators bring to health care organizations.

Complementary Approaches to Improving Glucose Control-Insulin and Incretins: Patient Case Studies in Action.

PURPOSE: The use of insulin and incretin-based therapies together has recently emerged as a new therapeutic option for patients with type 2 diabetes. This approach can be used across the continuum of diabetes and is supported by clinical trial evidence. To illustrate how these data may apply to clinical care, this supplement uses patient case studies to provide clinical context for diabetes educators. Relevant medical literature was searched and cited. Search terms included insulin, DPP-4 inhibitors, GLP-1 receptor agonists, hypoglycemia, and weight gain. CONCLUSION: Insulin remains the most potent glucose-lowering agent available for the treatment of type 2 diabetes but has limitations, primarily of hypoglycemia and secondarily of weight gain. The addition of incretin-based therapies complements the glucose-lowering potential of basal insulin, without increasing the risk of hypoglycemia, potentially allowing for lower doses of insulin and without increasing weight gain (DPP-4 inhibitors) or possibly with weight loss (GLP-1 receptor agonists). Incretin-based therapies offer advantages over prandial insulin to address postprandial hyperglycemia.

Diabetes and the patient-centered medical home.

Should you choose to adopt the PCMH, you need to recognize that there will be early adopters and there will be skeptics and it will most likely require a culture change for your organization. Starting small with a targeted population, such as diabetes, is helpful in allowing everyone an opportunity to test this change before implementing it with all patients. You will likely struggle with IT and you can expect confusion as to how the PCMH and care coordination fit with the day-to-day work flow. And, everyone will struggle with staff turnover at some point. This will make it especially necessary to maintain organizational memory of the process. In summary, the core concepts of the PCMH have demonstrated results. However, to get there, leadership support for not only the concept but also for the work is essential. Although the application and certification are important, the real results come from embedding the principles in your standard operating procedures. The PCMH becomes the way you do your work.

Practical aspects of insulin pen devices.

Insulin pen devices have several advantages over the traditional vial-and-syringe method of insulin delivery, including improved patient satisfaction and adherence, greater ease of use, superior accuracy for delivering small doses of insulin, greater social acceptability, and less reported injection pain. In recent years, pens have become increasingly user-friendly, and some models are highly intuitive to use, requiring little or no instruction. Despite this progress, uptake of these devices in the United States has not matched that in many other areas of the world. There is a need for improved awareness of the current characteristics of insulin pen devices among United States health care professionals. Knowledge of the design improvements that have been incorporated into pens, both to address patient needs and as a result of the improved technology behind the device mechanics, is essential to promoting the use of insulin pen devices. This review highlights some of the practical aspects of pen use and discusses the factors to be considered when selecting among different insulin pens.

Randomized trial of quality improvement intervention to improve diabetes care in primary care settings.

OBJECTIVE: To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics. RESEARCH DESIGN AND METHODS: Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention. RESULTS: All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35). CONCLUSIONS: This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

Identifying individuals at risk for the development of type 2 diabetes mellitus.

OBJECTIVE: To describe a population-based approach to the identification of individuals at high risk for the development of type 2 diabetes mellitus (DM). STUDY DESIGN: A prospective analysis of the incidence of DM in low- and high-risk groups. PATIENTS AND METHODS: Questions associated with the risk of developing DM were incorporated into a health risk assessment (HRA), and health plan members were invited to complete the HRA as part of worksite health promotion efforts or medical clinic visits. Points were applied to the risk factors for DM, and individual HRA responders were assigned to low- or high-risk groups. A total of 16 427 members completed the HRA. To assess the incidence of new cases of DM, follow-up time was up to 4.8 years (mean, 2.55 years). New-onset DM cases were identified using International Classification of Diseases, Ninth Revision, coding for DM during the timeframe subsequent to HRA completion. RESULTS: The incidence of new DM at the end of the study was 3.5% in the high-risk group and 0.7% in the low-risk group (P < .001). CONCLUSIONS: Identification of individuals at risk for DM using this HRA approach increases by 5-fold the likelihood that the targeted risk reduction efforts will reach the right individuals. This approach allows for resource-efficient targeted intervention efforts designed to reduce the incidence of new DM cases.