Management of type 2 diabetes in primary care setting : promoting insulin initiation and supporting continuity of care

Abstract

 Pre-insulin class had been launched since 2015 to promote insulin initiation among type 2 diabetes (T2DM) patients with suboptimal glycemic control in a primary care setting in Hong Kong. Little was known for insulin initiation rate among class referees although it was launched. Meanwhile, an innovative individualised intervention was needed to promote early insulin initiation. During Coronavirus Disease 2019 Pandemic, drug refill service was introduced but its utilisation rate and users’ profile were not evaluated. This thesis involved three studies aimed to (i) estimate insulin initiation rate and identify related factors among pre-insulin class referees, (ii) develop individualized intervention in promoting insulin acceptance and initiation, and examine its effectiveness, (iii) estimate utilisation rate of drug refill service among T2DM patients during pandemic and identify users’ characteristics. First, a secondary data analysis of a retrospective cohort of the pre-insulin class referees from 1 January 2015 to 31 August 2020 was conducted. Data were retrieved from the Clinical Data Analysis and Reporting System (CDARS). Insulin initiation rate was estimated, and related factors were identified by multiple logistic regression. Second, an individualised intervention based on a 15-minute brief motivational interviewing (MI) guided by a screening questionnaire for barriers in insulin initiation was developed for promoting timely insulin initiation. A quasi-experimental study was conducted from 1 October 2019 to 30 April 2020 in a primary care setting to examine the effectiveness of this intervention on promoting insulin acceptance among T2DM patients with glycosylated haemoglobin (HbA1c) ≥7.5%, as compared with usual care only. Exact chi-square test compared group difference in proportions of insulin acceptance and initiation. Third, another secondary data analysis was conducted from 22 January to 30 June 30 2020 by retrieving data from CDARS to estimate the proportion of T2DM patients utilized the drug refill service in two primary care clinics of Southern District. Multiple logistic regression model was used to identify characteristics associated with utilisation. Among 323 pre-insulin class referees with mean (±SD) HbA1c 8.7%±1.1 and 86.0% diagnosed T2DM>10 years, 21.7% (95%CI=17.4%, 26.7%) started insulin. Self-monitoring blood glucose (adjusted OR=2.02, 95%CI=1.15, 3.56; p=0.015) and HbA1c (adjusted OR=1.31, 95%CI=1.04, 1.66; p=0.024) but not class attendance, were significantly associated with insulin initiation. There were 143 Chinese patients (control 64; intervention 79) with mean HbA1c 8.3%±1.0, and 56.6% diagnosed T2DM>10 years recruited to the quasi-experimental study. Higher insulin acceptance and initiation rate were observed in intervention group (acceptance: 31.6% vs. 4.7%, p<0.001; initiation: 10.1% vs. 1.6 %, p=0.042). During special arrangement for drug refill service period, 6,946 T2DM patients, with mean HbA1c 6.8%±0.9 and 42.1% with diabetes >10years, were studied. Among them, 247 used drug refill service, giving utilization rate of 3.6% (95%CI: 3.1%, 4.0%). Patients, aged ≥70years, being house-worker, unemployed/retired, non-drinker, underweighted or over-weighted, were independently associated with higher drug refill service utilization. Although insufficient evidence showing pre-insulin class could promote insulin initiation while individualized intervention helped to promote timely insulin acceptance and initiation among T2DM patients. Low utilisation of drug refill service suggested continuity of diabetic care should be supported by more alternatives.