An integrative review of the psychosocial facilitators and challenges of continuous subcutaneous insulin infusion therapy in type 1 diabetes

Clinical Translation and Implementation of a Bioartificial Pancreas Therapy: A Qualitative Study Exploring the Perspectives of People With Type 1 Diabetes

Background

The development of a hybrid beta-cell replacement approach, referred to as a personalized, transplantable bioartificial pancreas (BAP), holds promise to treat type 1 diabetes (T1D). This interview study aimed to explore patients' expectations, needs, concerns, and considerations when considering to undergo a BAP transplantation.

Research Design and Methods

Semistructured interviews were conducted with 24 participants diagnosed with T1D. Data collection stopped once data saturation was reached. Audio recordings of the interviews were transcribed verbatim. The interviews were independently analyzed by 2 researchers. A qualitative content analysis using an inductive approach was used.

Results

Three main themes emerged as follow: (1) hoped-for benefits, (2) concerns and decision-making considerations, and (3) procedural aspects. First, the participants expected benefits across medical, psychological, and social domains. Over these 3 domains, 9 subthemes were identified, including improved clinical outcomes, a cure for diabetes, more headspace, emotional relief, a shift in responsibility, protection of privacy, improved flexibility in daily life, less visible diseases, and improved relationships with others. Second, concerns and considerations about undergoing a BAP transplant comprised adverse events, the functionality of the BAP, the surgery procedure, the biological materials used, the transplant location, and the intrusiveness associated with follow-up care. Finally, procedural considerations included equitable access, patient prioritization, and trust and control.

Conclusions

Incorporating insights from this study into the clinical development and implementation of the BAP is crucial to ensure alignment of the product and procedures with the needs and expectations of people with T1D.

Effectiveness of educational and behavioural interventions for reducing fear of hypoglycaemia among adults with type 1 diabetes: Systematic review and meta-analyses

AIMS

To summarize and critically appraise evidence regarding the effectiveness of educational and/or behavioural interventions in reducing fear of hypoglycaemia among adults with type 1 diabetes.

METHODS

Systematic searches of medical and psychology databases were conducted. Risk-of-bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools. Data were synthesized using random-effects meta-analyses for randomized controlled trials (RCTs) and narrative synthesis for observational studies.

RESULTS

Five RCTs (N = 682) and seven observational studies (N = 1519) met the inclusion criteria, reporting on behavioural, structured education and cognitive-behavioural therapy (CBT) interventions. Most studies assessed fear of hypoglycaemia using the Hypoglycaemia Fear Survey Worry (HFS-W) and Behaviour (HFS-B) subscales. Mean fear of hypoglycaemia at baseline was relatively low across studies. Meta-analyses showed a significant effect of interventions on HFS-W (SMD = -0.17, p = 0.032) but not on HFS-B scores (SMD = -0.34, p = 0.113). Across RCTs, Blood Glucose Awareness Training (BGAT) had the largest effect on HFS-W and HFS-B scores, and one CBT-based program was as effective as BGAT in reducing HFS-B scores. Observational studies showed that Dose Adjustment for Normal Eating (DAFNE) was associated with significant fear of hypoglycaemia reductions.

CONCLUSIONS

Current evidence suggests that educational and behavioural interventions can reduce fear of hypoglycaemia. However, no study to date has examined these interventions among people with high fear of hypoglycaemia.

Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes

PURPOSE OF REVIEW

Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption.

RECENT FINDINGS

Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.

'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

INTRODUCTION

Continuous subcutaneous insulin infusion (CSII) treatment is beneficial for obtaining glycaemic control for many persons with type 1 diabetes mellitus (T1DM). Still, some individuals do not obtain improved HbA1C levels despite CSII treatment, and there is a lack of evidence regarding how psychosocial factors may influence glycaemic control. Thus, we aimed to explore the attitudes and experiences of self-management among people with T1DM and suboptimal glycaemic control despite CSII treatment.

RESEARCH DESIGN AND METHODS

A qualitative inductive design was applied, and four FGDs were performed with 37 adult men and women of various ages and duration of T1DM. All participants had suboptimal glycaemic control despite CSII treatment. Transcripts were analysed using qualitative manifest and latent content analysis.

RESULTS AND CONCLUSION

The themes Searching for freedom and flexibility and Preferring safety and the well-known illustrated the divergent psychosocial strategies adapted, which both resulted in suboptimal glycaemic control. The technical devices and their effects on glycaemic levels may be challenging to understand and adjust to fit people's lifestyles. The rapid advances of technology devices in diabetes care can potentially change peoples' lives, but is the educational support developing as fast? Multifaceted web-based education of high quality, including tailored support with a person-centred focus, is more important than ever before as the need for technical knowledge and understanding may put further disease burdens to patients with T1DM on CSII treatment.

Technological Developments and Quality of Life in Type 1 Diabetes Mellitus Patients: A Review of the Modern Insulin Analogues, Continuous Glucose Monitoring and Insulin Pump Therapy

BACKGROUND

Type 1 Diabetes Mellitus (T1DM) is a chronic autoimmune disease, which is characterized by an increased prevalence worldwide, which, in fact, tends to take extensive dimensions. The recent rapid development of science and technology has significantly contributed to the improvement of the management of type 1 diabetes mellitus, both in achieving the required euglycaemic regulation and reducing the psychological burden associated with the disease, consequently improving the quality of life of the patients with type 1 diabetes mellitus.

METHODS

A literature review from 2010, related to the contribution of the modern insulin analogues, continuous glucose monitoring and the insulin pump, was performed using Scopus, ScienceDirect and PubMed databases.

RESULTS

Studies included in the review support a direct and indirect association of technological innovations with the quality of life. The use of type 1 diabetes mellitus technology was negatively associated with the frequency of the hypoglycaemias and the value of the glycosylated hemoglobin, while at the same time, the development and use of the related technology were highly associated with an improvement in the quality of life.

CONCLUSION

Patients' quality of life is an indicator of the management of type 1 diabetes mellitus, and it is just as important as glycaemic regulation. Through this review, it was concluded that a better quality of life of T1DM patients was associated with the improvement of glycosylated hemoglobin and hypoglycemic episodes.

Insulin Pump Treatment in Adults with Type 1 Diabetes in the Capital Region of Denmark: Design and Cohort Characteristics of the Steno Tech Survey

INTRODUCTION

Insulin pump therapy can improve quality of life and glycaemic outcomes for many people with type 1 diabetes (T1D). The multidimensional Steno Tech Survey study aims to investigate why some insulin pump users do not achieve treatment goals. In this article, we present the study design and analyse differences in population characteristics between responders and non-responders.

METHODS

In June 2020, all 1591 insulin pump users (≥ 18 years) in the Capital Region of Denmark were invited to participate in an online questionnaire that evaluated several dimensions of insulin pump self-management and psychosocial health. Demographic, socioeconomic and clinical characteristics, including age, sex and HbA1c, of the cohort were identified via national registries. Predictors of questionnaire response/non-response were explored with logistic regression analysis.

RESULTS

In the full study population, 58% were female, median age was 42 years and median HbA1c was 58 mmol/mol (7.5%); 30% had HbA1c < 53 mmol/mol (7.0%). In total, 770 individuals (48%) responded to the questionnaire. Logistic regression analysis showed that 50+ years of age (odds ratio [OR] = 2.3, 95% confidence interval [CI]: 1.4-3.8), female sex (OR = 1.3, CI: 1.02-1.6), being married (OR = 1.8, CI: 1.3-2.4) and having long higher education (OR = 1.6, CI: 1.004-2.5) were significantly associated with a higher likelihood of responding to the survey; the opposite was found for HbA1c from 64 to < 75 mmol (8.0-9.0%) (OR = 0.6, CI: 0.4-0.8) and HbA1c ≥ 75 mmol/mol (≥ 9.0%) (OR = 0.2, CI: 0.1-0.3).

CONCLUSIONS

The established Steno Tech cohort enables future analysis of a range of psychosocial and behavioural aspects of insulin pump self-management. Interpretation and generalization of findings should consider observed differences between responders and non-responders.

Psychosocial factors associated with HbA1c in adults with insulin pump-treated type 1 diabetes: a systematic review

AIMS

To identify currently available studies on the association between psychosocial factors and HbA_1c in adults with insulin pump-treated type 1 diabetes, by performing a systematic review of the literature.

METHODS

MEDLINE, Embase, CINAHL and PsycINFO were searched for original studies on the association between psychosocial factors and HbA_1c in ≥ 50 adult, non-pregnant, insulin pump users with type 1 diabetes.

RESULTS

The search resulted in 1777 unique records, of which eight were eligible for inclusion. All identified studies were observational, with sample sizes ranging from 51 to 214. Seven different psychosocial factors were investigated in the eight studies. Study analysis suggested that HbA_1c may be associated with diabetes numeracy and quality of life. There were no indications of associations between HbA_1c and fear of hypoglycaemia or self-efficacy. Results regarding associations between HbA_1c and coping style, diabetes distress and locus of control were inconsistent.

CONCLUSIONS

This systematic review summarizes the currently limited information on the association between psychosocial factors and HbA_1c during insulin pump therapy. The evidence base of the included studies was weak, and this review highlights the need for more research in these areas, with improved methodological and theoretical frameworks, including exploration of a broader spectrum of psychosocial variables and their potential association with HbA_1c and other metabolic outcomes. (PROSPERO International prospective register of systematic reviews registration no: CRD42020145705).

Efficacy of an Education Program for People With Diabetes and Insulin Pump Treatment (INPUT): Results From a Randomized Controlled Trial

OBJECTIVE

Continuous subcutaneous insulin infusion (CSII) is the most advanced form of insulin delivery, but it requires structured education to provide users with the necessary knowledge/skills and to support their motivation. Currently, no structured education program designed to provide this training has been evaluated. We developed a CSII-specific, structured education program (Insulin Pump Treatment [INPUT]) and evaluated its impact on glycemic control, behavior, and psychosocial status.

RESEARCH DESIGN AND METHODS

This was a multicenter, randomized, parallel trial with a 6-month follow-up. Eligible participants (age 16-75 years) currently were treated with insulin pump therapy. Participants were randomly assigned (1:1) to the INPUT program or to usual care using a computer-generated algorithm, with study center as the stratification factor. The primary outcome was HbA_1c change from baseline to 6 months. Secondary outcomes were incidence of severe hypoglycemia and changes in behavioral and psychosocial measures.

RESULTS

Between 1 April 2016 and 26 April 2016, 268 people with diabetes and a mean duration of CSII therapy of 9.5 years were randomly assigned to the INPUT group (n = 135) or control group (n = 133). At 6 months, HbA_1c improved in the INPUT group (8.33 ± 0.8 vs. 8.04 ± 0.9; P < 0.0001) but not in the control group (8.33 ± 1.0 vs. 8.27 ± 1.0; P = 0.11). The between-group difference in HbA_1c reduction was significant, favoring INPUT (-0.28% vs. -0.06%, Δ -0.22%, 95% CI -0.38 to -0.06; P = 0.0029). The incidence rate ratio of severe hypoglycemia was 3.55 times higher for participants in the control group than for those in the INPUT group (95% CI 1.50-8.43; P = 0.0041).

CONCLUSIONS

The INPUT education program led to a significant improvement in glycemic control and incidence of severe hypoglycemia in insulin pump users.