Tip:
Highlight text to annotate it
X
John Brill: My community education project
was to develop a patient education handout detailing
how to use short acting insulin. The patient that was
the trigger for this idea was a patient of mine at St.
Luke's Family Practice Center on the south side of
Milwaukee. She was a 72-year-old Latino woman who had
had diabetes for about eight years with never very
good control. Her last couple of hemoglobin A1Cs
had been in the 8 to 9 range. She was on the
maximally tolerated doses of oral medications that she
could take. And I broached the idea of insulin a
couple of times, but she was really pretty opposed to
trying that and really didn't want to go there. Of
course, on a weekend when I was out of town, she had a
heart attack, and was admitted to the hospital. In
the hospital she was started on insulin because of not
wanting to use her oral medications. She did receive
teaching from a diabetic educator while there, and was
given prescriptions for all of the necessary equipment
and insulin and was sent home with that. But she
called me a couple days later saying that her blood
sugars were running high and in talking with her, I
discovered that she wasn't using the short acting
insulin at all, she was just using her glargine
insulin. And I wasn't able to quite get to the bottom
of why she wasn't using it on the phone, so I asked
her to come in for a session with some of our clinic
staff. Just as a little bit of background on
diabetes, diabetes is one of the most common and
severe health care problems currently facing people in
the United States. There is over 17 million people
with diabetes, which is about 8% of all adults and the
prevalence is increasing tremendously, 13% in the last
three years alone. Some of this is probably due to
increased testing and increased detection, but some of
it is also probably due to increasing prevalence,
mostly related to obesity. We're starting to see
younger and younger people even middle school students
developing type 2 diabetes. In diabetes is very much
an issue for primary care, it's one of the top ten
reasons why people come to see a primary care
physician, and it's also one of the, one of the
biggest, if not probably the single disease that costs
the most amount of money in the United States. In
2007, 174 billion dollars was spent on direct and
indirect costs of diabetes, that's almost 10% of all
health care dollars according to the American Diabetes
Association. And diabetics are treated as, you know,
in a couple of different ways. About 1 out of 6 is
currently treated just with therapeutic lifestyle
changes, over half are on oral medications alone, but
almost 30% are on insulin either by itself or in
combination with oral agents. So getting back to our
patient, she met with a pharmd and a nurse to go over
how to use her insulin. I had questioned, the patient
is latina, she's pretty bilingual, but I had a
question in my mind if that might be part of the
issue, but both the pharmd and the nurse that she met
with were bilingual and said that she understood
English as well. It turned out that she was very
afraid of hypoglycemia, she lives alone and was very
concern that had she could get hypoglycemic and there
would be no one to help her, so a very appropriate and
reasonable concern. And both the nurse and the
pharmacist commented that she just needed a lot of
repetition, a lot of reassurance, going through things
over and over. So it occurred to us that a patient
education handout or some materials that we could give
her to both help with the teaching as well as to have
some reinforcement at home would be very helpful. So
I started to look for something like this. I looked
through patient education materials that were
available from the American Diabetes Association, from
familydoctor.org, which is the patient education
website of the American Academy of Family Physicians,
from some Aurora resources, also just did a Google
search for patient education handouts on short acting
insulin and diabetes. There is also a website which
is called two tuotromedica.com which has lots of
information in Spanish. What I turned up was a number
of websites which wasn't particularly useful for this
patient because she didn't have access to them. Some
of them kind of went through step by step process. We
found a number of handouts on how to give insulin
itself, which didn't really seem to be her exact
issue, but nothing very generally on how to use short
acting insulin. Most sites that I came across seemed
to be written at a pretty high educational level, one
exception being familydoctor.org which was pretty easy
to read. So we decided to create a patient education
handout specifically on how to use short acting
insulin. We wanted it to be very simple, easy to
remember, and we came up with a mnemonic of TIE, for
test, insulin, eat. We wanted it to be visually
attractive, something people would want to maybe put
on that I refrigerator, have some simple pictures and
be easy to read. And have a reading level that was at
a minimum for all patients. So the memory scheme that
we came up with is TIE, which stands for test, insulin
and eat. There are lots of handouts that show how to
use glucometer and lancets to check your blood sugar,
so we felt we could tie that into existing handouts.
Giving insulin, and again, lots of already existing
information about how to do the injection, and then
eating, so needing to have something in your system to
prevent hypoglycemia. In terms of the process for
this, we first I wrote a draft of it, I talked over
with one of our pharmacists who suggested some
additional medications and also suggested having some
sliding scale component to it. We did a readability
test. Initially it was written at a 12th grade level,
and there is, it doesn't give you really instructions
on how to decrease that, so I had to kind of play
around with that. I found that most of this high
reading level was from a lot of polysyllabic words,
and getting rid of a number of those brought it down
to a 7th grade reading level. I then piloted it with
a couple of patients to get their thoughts and input
and opinions. I didn't really get any very
constructive criticism from them, but they did give me
some ways that they thought it could be useful. Some
of the challenges that we encountered were how to lay
it out in such a way that it was friendly, still kept
attractive, had enough information but not too much,
again, how to get to the low reading level, how to use
words that replace some of those longer words, and
sometimes there is no really shorter equivalent.
Integrating the sliding scales with a bit of a
challenge, too. We decided to keep it very simple
with just a one step for if the blood sugar was too
high and one step for if it was too low. And then
found some pictures. And this was actually a little
bit of a challenge than I expected. We found
initially a number of pictures that were in color, but
found that when we reproduced them in black and white,
the plate of food that looked delicious and wonderful
and diverse in color looked like a mash of not really
anything when it was in black and white. So we think
that this patient education handout can be useful for
primary care physicians who are talking with their
patients about going on insulin or who might need it
in the future to try to quiet down some of their
concerns. It might help the staff time, especially in
places that don't have ready access to diabetic
educators or nurse educators or pharmacists that can
assist. And for patients, it could be helpful in a
couple of ways. One is to reassure that they're not
going to become hypoglycemic, to kind of keep the
order of events in mind, and also contains a
references for what doses to use. Again, something
that they could kind of put on their refrigerator
refer to. Some of the limitations of this, it doesn't
talk about the longer acting insulin. I guess my
experience has been that that hasn't been as much of
an issue, and that is something that probably could be
just written in or added. It does reference some
other handouts for injection and also for how to, how
to handle hypoglycemia, so patients would need to have
access to those as well. Only a very simple sliding
scale and the notion here was just that it would get
too complicated and too wordy if we tried to put in
more details about that. A problem with using a paper
form is that any time one's insulin doses were
changed, you would have to give a whole new form or
else start writing it and start crossing things out
which could get pretty messy. And just again, with
the paper format, in a full page like this, it's
probably not something that patients would take with
them. So some future steps that could be useful for
this, one would be to translate into Spanish, in
particular, because of the high rates of diabetes in
the Latino population as well as into Hmong. It would
be nice to have more culturally diverse patient
pictures, although actually, that was one thing where
going into black and white sort of blurred those
lines, but especially with the high prevalence of
diabetes in African American patients, it would be
nice to have pictures that reflect other cultures. It
would be potentially useful to have another version
that had a more complex sliding scale, so could just
replace this sliding scale section with one that had a
more specific range. And finally, a really
interesting idea that came up as we were talking, was
that many of the glucometers now really have a lot of
memory, and it would be interesting to work with some
glucometer manufacturers to have more reference
information for patients. So it seems like it would
be relatively simple to have a handout like this that
was part of a glucometer software package, a way to
program the glucometer to include the doses of insulin
that the patient is on. It would be ideal to have the
sliding scale, for example, pop up telling the patient
exactly how much insulin they should use depending on
what their blood sugars were. So overall, we thought
that this would be a really useful handout that could
help with the almost 30% of diabetics in this country
that are using insulin. Any questions?