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Title: A study of factors explaining blood glucose control in patients with insulin-treated type 2 diabetes
Author: Ellis, Kathleen Elizabeth
ISNI:       0000 0004 8505 5181
Awarding Body: King's College London
Current Institution: King's College London (University of London)
Date of Award: 2020
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Background: Many people with type 2 diabetes (T2DM) require insulin therapy to manage glucose levels and reduce the risk of diabetes complications. However, a significant proportion of patients with T2DM receiving insulin therapy do not achieve adequate control over their glucose levels, which increases their risk of complications. It is important, therefore, to increase our understanding of factors that may influence insulin use in the T2DM population to improve the insulin support provided to patients. As most insulin care for T2DM is now provided in primary care by Practice Nurses (PNs) and General Practitioners (GPs), it is important to consider these factors in that context. Therefore, this study set out to provide an integrated analysis of the perspectives of both patients and primary care healthcare professionals (PC HCPs) based on their experiences of current insulin care provision. Methods: A mixed-methods approach was used to examine perspectives of insulin-treated T2DM patients and HCPs recruited from a range of general practices in terms of size and diabetes expertise within the practice teams. The research incorporated: a cross-sectional postal survey of insulin-using patients with T2DM, with supplemental structured telephone interviews; and in-depth semi-structured faceto- face qualitative interviews with patients and PC HCPs (PNs and GPs). The survey and structured interview data were analysed statistically in SPSS v22 to provide: descriptive data detailing the patient characteristics associated with different levels of glycaemic control (glycated haemoglobin; HbA1c); and bivariate analyses and logistic regression to model the associations between patient-level factors and glycaemic control. The qualitative interview data were analysed thematically using the interpretive phenomenological approach. Findings: Of those invited, 50% (n = 201) of eligible patients, mean age 70 years (range 37-90), completed the primary survey, of which 62% (n = 124) participated in the supplemental structured telephone interviews. The mean HbA1c of the survey participants was 64 mmol/mol (SD = 16.9, range 37-168), and duration of T2DM and of insulin was 17 years (SD = 7.58) and eight years (SD = 6.15) respectively. The participants were grouped by HbA1c as follows: optimal control (HbA1c ≤59 n = 95, 47%); moderate control (HbA1c >59 to ≤69, n = 50, 25%); and suboptimal control (HbA1c >69, n = 56, 28%). A regression analysis using a dichotomised HbA1c (≤59 mmol/mol = 1 and >59 mmol/mol = 0) indicated that depression scores (Patient Health Questionnaire-9; PHQ-9) (p = .03) and diabetes duration (p = .04) were negatively and positively associated with glycaemic control, respectively. The interview data indicated that the following factors were important in moderating insulin use and its impact on glucose control: patient understanding of insulin and associated self-management behaviours; patient motivation; the expertise and support of the HCPs; and the type/level of insulin support provided by the primary care team. Conclusions: The study findings have revealed the factors that mediate the impact of insulin on glycaemic control are multifactorial, residing at the patient, health professional and system level. The study also highlights the importance of individualising the insulin management plan in respect of insulin choice, glucose targets and most importantly the patient's preference and capacity to self-manage. This has highlighted areas where future developments are required to improve the provision of insulin support in primary care and these include enhanced educational support for both patients and professionals, with an emphasis on patient-centred integrated care models.
Supervisor: Forbes, Angus Scott ; Winkley-Bryant, Kirsty ; Mulnier, Henrietta Elizabeth Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available