Kuo Charlotte R, Quan Judy, Kim Sarah, Tang Audrey Hui-Yu, Heuerman Deborah Payne, Murphy Elizabeth J
Diabetes Clinic, San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
Division of General Internal Medicine, University of California, San Francisco, CA, USA.
J Clin Nurs. 2017 Jun;26(11-12):1705-1713. doi: 10.1111/jocn.13577. Epub 2017 Feb 8.
To evaluate the effect of an 'insulin introduction' group visit on insulin initiation and A1C in adults with type 2 diabetes.
The clinical course of type 2 diabetes involves eventual beta-cell failure and the need for insulin therapy. Patient psychological insulin resistance, provider-related delays and system barriers to timely initiation of insulin are common. Group visits are widely accepted by patients and represent a potential strategy for improving insulin initiation.
A single two-hour group visit in English or Spanish, facilitated by advanced practice nurses, addressed psychological insulin resistance and encouraged mock injections to overcome needle anxiety.
A retrospective review of 273 patients referred from 2008-2012, determined characteristics of group attenders, rates of mock self-injection, rates of insulin initiation and changes in A1C from baseline to 2-6 and 7-12 months postgroup. Change in A1C was compared to patients referred to the group who did not attend ('nonattenders').
Of 241 patients eligible for analysis, 87·6% were racial/ethnic minorities with an average A1C of 9·99%. Group attendance rate was 66%; 92% performed a mock injection, 55% subsequently started insulin. By 2-6 months, A1C decreased by 1·37% among group attenders, and by 1·6% in those who did a mock injection and started insulin. Fewer nonattenders started insulin in primary care (40%), experiencing an A1C reduction of 0·56% by 2-6 months. A1C improvements were sustained by 7-12 months among group attenders and nonattenders who started insulin.
Nurses can effectively address patient fears and engage patients in reframing insulin therapy within group visits.
This one-time nurse-facilitated group visit addressing psychological barriers to insulin in a predominantly minority patient population resulted in increased insulin initiation rates and clinically meaningful A1C reductions.
评估“胰岛素引入”小组就诊对2型糖尿病成人患者胰岛素起始治疗及糖化血红蛋白（A1C）的影响。
2型糖尿病的临床病程最终会导致β细胞功能衰竭，进而需要胰岛素治疗。患者对胰岛素的心理抗拒、医护人员导致的延迟以及及时起始胰岛素治疗的系统障碍都很常见。小组就诊被患者广泛接受，是改善胰岛素起始治疗的一种潜在策略。
由高级执业护士协助开展的一次时长两小时的英语或西班牙语小组就诊，解决了患者对胰岛素的心理抗拒问题，并鼓励进行模拟注射以克服针头焦虑。
对2008年至2012年转诊的273例患者进行回顾性分析，确定小组参与者的特征、模拟自我注射率、胰岛素起始治疗率以及从基线到小组就诊后2至6个月和7至12个月时A1C的变化。将A1C的变化与转诊至该小组但未参加的患者（“未参与者”）进行比较。
在241例符合分析条件的患者中，87.6%为少数族裔，平均A1C为9.99%。小组就诊率为66%；92%进行了模拟注射，55%随后开始使用胰岛素。到2至6个月时，小组参与者的A1C下降了1.37%，进行模拟注射并开始使用胰岛素的患者A1C下降了1.6%。在初级保健中，开始使用胰岛素的未参与者较少（40%），到2至6个月时A1C降低了0.56%。在开始使用胰岛素的小组参与者和未参与者中，A1C的改善在7至12个月时得以持续。
护士可以在小组就诊中有效解决患者的恐惧，并促使患者重新认识胰岛素治疗。
在以少数族裔为主的患者群体中，由护士协助开展的这次一次性小组就诊解决了胰岛素治疗的心理障碍，提高了胰岛素起始治疗率，并使A1C有了具有临床意义的降低。
