Why persons with type 1 diabetes and continuous insulin infusion fail to achieve optimal glycemic control was the subject of a recent focus group analysis conducted among 37 adult men and women.
Despite the known advantages of continuous subcutaneous insulin infusion (CSII) for persons with type 1 diabetes (T1D), many who use this technology still fail to achieve optimal glycemic control, leading the investigators of a new study in BMJ Open to conclude that patients need more education on diabetes technology use.
Among the 23 women and 14 men with T1D who were included in their study’s 4 focus groups—recruited from 2 diabetes centers in the County Council of Östergötland, Sweden—the study authors saw that strategies for self-management of glycated hemoglobin A1C (HbA1C) varied widely as a result. Because of this, they looked into the psychosocial factors that may influence ineffective T1D management among users of CSII. To be included, participants had to be older than 18 years, have T1D and be using CSII, and have an HbA1C measure greater than 165 mg/dL (57 mmol/mol). The women could not be pregnant.
The focus group interviews, which were recorded, focused on 3 principal areas: views/beliefs related to T1D, daily life with T1D, and T1D self-management when using CSII. The mean (SD) patient age was 50.8 (14.7) years; HbA1C, 74 (12) mmol/mol; and T1D duration, 28.5 (13.8) years.
“Understanding how people with suboptimal glycemic control, despite CSII treatment, reason and act on their self-management should be a research and clinical priority,” the authors wrote, “and assist diabetes care services to develop tailored support and problem solving for these individuals.”
Close to half of the participants (48.6%) used devices where there was an option to measure their carb intake, 43.2% used continuous glucose monitors, and there was no cited use of a sensor-augmented device.
Overall, more women than men used diabetes technology. The 2 main themes the investigators gleaned from the focus groups were that participants were either searching for freedom and flexibility or they preferred safety and the well known when managing their T1D—which led to the varied results seen in self-management. For example, those preferring freedom often decided to be nonadherent to the treatment their T1D required because of their present living conditions, which was in stark contrast to those who preferred safety and liked being on a regular multi-insulin dose schedule.
Delving deeper, the investigators saw that those who expressed wanting more freedom did so because they did not like being different from others, and therefore initiating CSII provided relief in social situations. However, devices were often hard to come by and health care professionals did not always heed their wishes. Some patients joined clinical trials just to have access to treatment. All stressed wanting to learn and know more about their treatment choices, despite also noting that they thought devices could be prohibitive and messy.
With the other theme, the investigators saw that participants were suspicious of the CSII diabetes technology, which is why they preferred multi-insulin dose treatment. Principal reasons were they thought their current dosing regimen was more conservative, issues with equipment leakage, learning to use devices was too complex and time consuming, and being forced to switch to CSII by their health care team.
The study authors noted that they also found health care professionals’ perceptions of their patients’ ability to manage their disease may influence the treatment options they offer, which can sometimes conflict with current guidelines and not account for the patients who want to know about options.
“Other options than standard diabetes care and support are needed to fully support people with a suboptimal glycemic balance to find acceptable solutions to maintain their self-management without increased disease burdens, especially in social situations,” the authors emphasized. “Studies have stressed the importance of additional diabetes care support. For example, psychological support and support to find alternative strategies are emphasized for improved glycemic control and quality of life without further increasing the treatment burden.”
Persson M, Leksell J, Ernersson A, Rosenqvist U, Hörnsten A. ‘Striving for freedom or remaining with what is well-known’: a focus-group study of self-management among people with type 1 diabetes who have suboptimal glycaemic control despite continuous subcutaneous insulin infusion. BMJ Open. Published online April 1, 2022. doi:10.1136/bmjopen-2021-057836