A Study of Factors Explaining Blood Glucose Control In Patients with Insulin Treated Type 2 Diabetes
The report presents a summary of my PhD research project to date investigating factors contributing to blood glucose control in patients with insulin treated type 2 diabetes (T2DM). The Research Scholarship supported my studies throughout year three of a part-time six-year doctorate with King’s College London. During that time I completed a literature review, conducted a cross-sectional survey, piloted the patient and healthcare professional (HCP) interviews, conducted the HCP interviews, and drafted the initial chapters of the thesis. The multiphase study is relevant to my role as an Advanced Nurse Practitioner in a large general practice in Kent which includes initiating and managing insulin treatment in T2DM patients.
Background
The number of patients with T2DM progressing to insulin is increasing due in part to the rising prevalence of T2DM but also because of the need to improve glucose control to prevent complications such as eye and kidney disease, and foot problems (Holman et al. 2008). Insulin treatment is now frequently managed by General Practitioners (GPs) and Practice Nurses (PNs) (Burden & Burden 2007, Ellis et al. 2011). While some practices have developed special provision of insulin initiation clinics there is consistent evidence to show that insulin may not be used to optimal effect in primary care (Dale et al. 2010, Khunti et al. 2016).
Insulin is currently the most potent glucose-lowering medicine and proven to be effective in treating T2DM yet many patients receiving insulin still have poor control (Khunti et al. 2016). Whilst some factors have been identified in the way insulin is utilised in primary care and how patients manage their insulin, this is still not fully understood (Davies et al. 2013). Therefore, gaining insight into patient and clinician perspectives is important in identifying ways to improve control.
Aim
To explore factors contributing to glycaemic control in people with T2DM treated with insulin from the perspectives of patients, PNs and GPs.
Objectives
- To determine barriers to insulin titration with patients and HCPs.
- To explore with patients their explanations for their glycaemic control.
- To elicit from patients the reasons, behaviours and practices they believe contribute to their control.
- To explore specific beliefs and practices related to insulin use.
- To examine the association between insulin utilisation and patient-level factors in relation to glycaemic control.
- To explore attitudes and practices of PNs and GPs in insulin management.
- To identify and explore system-level factors that contribute to insulin management in primary care.
- To consider interactions between patient, professional and system factors in insulin management in primary care.
MIXED METHODS DESIGN
The project is being conducted in five distinct phases:
- Literature Review
- Quantitative Cross-Sectional Survey
- Qualitative Study 1. Interviews with PNs and GPs
- Qualitative Study 2. Interviews with Patients
- Triangulation of the qualitative and quantitative data
Phase 1. Literature Review
A comprehensive review provided an important theoretical platform and in the analysis of the data. This included a thematic meta-synthesis of 35 studies of the views of people with insulin treated T2DM, and of primary care HCPs, on insulin use and management. Twelve key themes were identified revealing the burden experienced by patients and the skills required by HCPs to support them. Patient-related themes included beliefs, social and psychological factors, hypoglycaemia, and therapy barriers. HCP themes included insulin skills, integrated healthcare, hypoglycaemia, and perceptions of patient-barriers. HCPs and patients perceived the insulin-related support given and received to be important in diabetes care.
Five analytical themes were generated forming a thematic framework identifying areas for further research including how clinicians elicit from patients their insulin-related concerns, injecting in public, self-adjustment of insulin doses, agreeing glucose goals, and inspiring more PNs and GPs to acquire insulin-related skills.
Phase 2. Cross-Sectional Survey
The purpose was to identify factors associated with glycaemic control in T2DM patients within a Clinical Commissioning Group in East Kent.
A survey was mailed to patients registered in five GP practices, who had received insulin for at least six months. Questions included how they perceived their control, management and support. Questions included assessments of well-being, depression, and numeracy literacy. Clinical data was extracted from medical records.
Results
Of 403 patients fulfilling the inclusion criteria, 201 (50%) completed and returned their surveys and 48% (n=96) had blood glucose levels in the optimal range (HbA1c≤59 mmol/mol). Age range was 37-90 years (mean 70 years); 58% male; and ethnicity predominantly white British (93%). Duration of diabetes was 2-43 years, and years on insulin 1-30. Statistical analysis has just began using IBM.SPSS v22. This will explore relationships and compare groups. Univariate and multivariate associations between sample characteristics and optimal (HbA1c ≤59 mmol/mol) or suboptimal (HbA1c >59 mmol/mol) control will be determined using logistic regression.
Phase 3. Qualitative Study 1.
The aim was to identify factors associated with control from PN and GP perspectives. Face-to-face in-depth interviews were undertaken with five PNs and four GPs from the practices, using an interpretive phenomenological approach to explore perceptions and experiences of supporting these patients. The analysis has not yet begun. NVivo software will be used to code and manage the data for a thematic analysis adopting a framework approach grounded in the thematic framework formulated from the meta-synthesis.
Phase 4. Qualitative Study 2
This will commence this year. The purpose is to explore with patients their experiences, perceptions, and explanations for their control. Face-to-face in-depth interviews will be conducted with at least thirty patients, or until data saturation, from those indicating in the survey their agreement to be contacted (n=142). These will generate rich data to enable thick descriptions, using an interpretive phenomenological approach. As with HCPs, a thematic analysis will be undertaken grounded in a thematic framework.
Phase 5. Triangulation
In this final phase quantitative survey data and qualitative interview data will be examined for associations between HCPs and patients. Where compatible, data will be merged to address the research aims in determining different factors associated with glycaemic control.
NHS Ethics and Governance
A favourable NHS ethical opinion was received from SE Scotland Research Ethics Committee 02, and assurance of governance from the Research Management and Governance Consortium for Kent and Medway. Consent was obtained in accordance with NHS research guidance (MRC 2014).
Throughout the development of the study patients have been actively involved in the research design, study documents, and piloting the interviews.
Summary
To be awarded a Florence Nightingale Foundation scholarship with the Band Trust donation is a privilege. I made good use of the year in terms of learning, conducting the study, and engaging with patients. An increasing number of T2DM patients are progressing to insulin yet many have suboptimal control with subsequent complications. The research project is therefore important in identifying ways to improve control in these patients and enhancing the support given by PNs and GPs. Nurses are required to practice in line with the best available evidence (NMC 2015). The research will add to the evidence and benefit patient care.