Group visits to encourage insulin initiation: targeting patient barriers.
OBJECTIVE
To evaluate the effect of an 'insulin introduction' group visit on insulin initiation and A1C in adults with type 2 diabetes.


BACKGROUND
The clinical course of type 2 diabetes involves eventual beta-cell failure and the need for insulin therapy. Patient psychological insulin resistance, provider-related delays and system barriers to timely initiation of insulin are common. Group visits are widely accepted by patients and represent a potential strategy for improving insulin initiation.


METHODS
A single two-hour group visit in English or Spanish, facilitated by advanced practice nurses, addressed psychological insulin resistance and encouraged mock injections to overcome needle anxiety.


METHODS
A retrospective review of 273 patients referred from 2008-2012, determined characteristics of group attenders, rates of mock self-injection, rates of insulin initiation and changes in A1C from baseline to 2-6 and 7-12 months postgroup. Change in A1C was compared to patients referred to the group who did not attend ('nonattenders').


RESULTS
Of 241 patients eligible for analysis, 87·6% were racial/ethnic minorities with an average A1C of 9·99%. Group attendance rate was 66%; 92% performed a mock injection, 55% subsequently started insulin. By 2-6 months, A1C decreased by 1·37% among group attenders, and by 1·6% in those who did a mock injection and started insulin. Fewer nonattenders started insulin in primary care (40%), experiencing an A1C reduction of 0·56% by 2-6 months. A1C improvements were sustained by 7-12 months among group attenders and nonattenders who started insulin.


CONCLUSIONS
Nurses can effectively address patient fears and engage patients in reframing insulin therapy within group visits.


CONCLUSIONS
This one-time nurse-facilitated group visit addressing psychological barriers to insulin in a predominantly minority patient population resulted in increased insulin initiation rates and clinically meaningful A1C reductions.
Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Charlotte R
CR
Kuo
Division of General Internal Medicine, University of California, San Francisco, CA, USA.|UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Judy
J
Quan
University of California, San Francisco, CA, USA.|Division of Endocrinology, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Sarah
S
Kim
Family Health Center, Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Audrey Hui-Yu
AH
Tang
General Medicine Clinic, Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Deborah Payne
DP
Heuerman
University of California, San Francisco, CA, USA.|Division of Endocrinology, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Elizabeth J
EJ
Murphy
D000328:Adult; D057179:Advanced Practice Nursing / Q000379:methods; D001294:Attitude to Health; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000451:nursing* / Q000523:psychology; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D035862:Vulnerable Populations
D007004:Hypoglycemic Agents; D007328:Insulin
group visit; insulin initiation; psychological insulin resistance; type 2 diabetes