By Annette M. Boyle
FORT HARRISON, MT — For some veterans, “insulin resistance” is not only a physiological condition, it is a state of mind — one the VA Montana Healthcare System in Fort Harrison hopes to overcome with a program that pilots the use of insulin pens.
Diabetes affects 31 percent of Vietnam-era veterans and more than one-fourth of all veterans and ranks as the fourth-most-expensive disease treated in the VA system, according to the VA Diabetes Quality Enhancement Research Initiative (QUERI) Center Strategic Plan released recently.
Kathy Rucker, R.D., C.D.E. demonstrates how to use an insulin pen.
Many of those veterans require insulin to control their diabetes but are reluctant to inject themselves using the standard syringe-and-vial treatment system, leaving them vulnerable to complications such as kidney failure, amputation and cardiovascular disease.
A plan to offer insulin pens to patients as a way to raise insulin adoption rates and improve disease management received funding as one of the 30 winning ideas proposed in the 2011 VHA Employee Innovation Competition. Kathy Rucker, RD, CDE, at Fort Harrison, submitted the idea to make taking insulin more palatable and easier for patients.
“I use the term ‘insulin resistance’ to refer not just to a person’s inability to use the insulin their body makes correctly but also to refer to patients who are resistant to taking action and providers or physicians who are a bit resistant to starting somebody on insulin,” said Rucker.
“When it comes time to start insulin with a patient and we talk about using a syringe, they are frequently very resistant. Often, people visualize a syringe as something that you might use in the hind end of a horse,” she added. “When we suggest an insulin pen, they don’t have the same resistance to doing it; it’s much less threatening.”
In November, the VA Montana Healthcare System began providing dose-controlled insulin pens (Novo Nordisk’s FlexPens) to diabetic patients instead of standard syringes and vials. Rucker said she hopes to enroll 400 patients in the test during the next year.
Device Use Limited on Formulary
Currently, insulin pen devices are on the VA formulary but are restricted to patients with diabetes who demonstrate an inability to draw insulin from a multi-dose vial into a syringe or who use short-acting analogs in intensive multi-dose therapy. In the Montana Healthcare System, the pens have previously been prescribed primarily for patients with limited vision or hand tremors.
A major concern about adopting pens on a broader basis has been cost. Glycemic treatment control alone cost the VA $450 million in 2008, according to the Diabetes QUERI Center.
Rucker suggested the pens may actually save money, however. “The cost for one type of insulin we use was exactly the same per unit, whether it came in a vial or in the pen,” she said. The difference is that “once you put a needle into a vial, you have 28 days until the insulin expires. So, somebody that’s on a very low dose ends up having to toss out the insulin that remains in the vial after that 28 days. Dose-controlled insulin pens have a limited amount in them, so even though the cost for the insulin is the same per unit, less is wasted.”
Rucker also noted that the pens eliminate the temptation among the thriftiest patients to continue to use insulin that has expired and risk diminishing control of blood-sugar levels.
Her greatest concern are the 16% of diabetic veterans with glycosylated hemoglobin (Hba1c) levels consistently above 9 and who she said “are more likely to use an insulin pen because it’s less obvious what they’re doing and much more convenient, particularly when they are away from home. I’ve had stories from guys who have gotten out their vial and syringe to take fast-acting insulin when they were in a restaurant and had somebody come after them thinking they’re using illegal drugs.”
A side benefit to the broader use of insulin pens is diminishing the supply of insulin syringes that can be obtained and misused by actual methamphetamine users, she added.Montana VA Program Replaces Insulin Syringes with Pens to Increase Compliance Cont
Ensuring the safety of insulin and avoiding hypoglycemia among diabetic patients has become a critical concern within the VA. More than 10% of all diabetes patients in the VHA experience a hypoglycemic event each year — and with Hba1c levels declining by 0.5% per year within that population, the rates may be rising, says the Diabetes QUERI Center. In addition, a December 2011 study in the Journal of the American Geriatrics Society showed that 20% to 27% of diabetic elderly veterans with cognitive impairment or dementia also suffered from hypoglycemia, making ensuring accurate dosing a high priority.
“While studies show that there is no difference in dosing accuracy between insulin pens and vials and syringes, many of our patients don’t see the lines on the syringes that well, so they guess. The numbers on the pens are easier to read, and they can hear the clicks. They know how many units of insulin they have,” Rucker explained.
To measure success of the program, the VA Montana Healthcare System will monitor glucose management by reviewing patients’ Hba1c levels, checking blood sugar logs and evaluating data that patients download directly from their glucose meters. The pilot team also will track the number and kind of emergency department visits and hospitalizations participants have during the program. Patients also will be surveyed about their views of the pens.
In addition to monitoring patient health and satisfaction, the team will assess staff perceptions online using Survey Monkey. Rucker said she expects the pens will increase satisfaction among healthcare educators and providers.
“If you’ve never drawn up something from a syringe and vial, it is kind of complicated and can be very frustrating for patients and educators,” she said. “It takes a lot more time than showing them how to use an insulin pen. If we can reduce the time spent on that component, we may have more time to teach other self-management skills.”
More than 100,000 employees have submitted nearly 15,000 ideas in the four Employee Innovation Competitions held since 2009. VA employees vote on the ideas using a crowd-sourcing platform, and the most popular are evaluated for implementation. The VA Innovation Initiative Executive Selection Board has funded pilots of 72 of the best ideas to date.
VA plans to introduce successful innovations into regular practice for adoption nationwide.
Already, Rucker has spoken with endocrinologists and nurses at the Nashville VA Medical Center who have expressed interest in the insulin pen program.
Offering options for insulin administration is consistent with the VA’s focus on patient-centered care.
“Everyone’s diabetes is a little different,” Rucker said, “so the one-size-fits-all approach that expects everyone to use an insulin vial and syringe simply doesn’t work.”
Some of the risks of diabetic foot ulcers (DFUs) are well-known, including infection and, in the most severe cases, amputation.
In a significant change, the American Diabetes Association’s 2018 guidelines advocate use of a glucose-lowering agent with proven cardiovascular benefit or mortality reduction in patients with Type 2 diabetes mellitus (T2DM) and co-morbid cardiovascular disease.