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Improving the treatment experience for patients with type 2 diabetes: Role of the nurse practitioner

Bartol, Tom NP, CDE (Family Nurse Practitioner)1

Author Information
Journal of the American Academy of Nurse Practitioners: April 2012 - Volume 24 - Issue - p 270-276
doi: 10.1111/j.1745-7599.2012.00722.x

Abstract

People with type 2 diabetes must manage their condition on a day-to-day basis, through lifestyle choices, home glucose monitoring, and sometimes medication. Patients, not clinicians, are responsible for most of the activities required for daily diabetes care, as they live with the disease 24 h a day. In order to manage diabetes effectively, patients need the knowledge, motivation, confidence, and skills to do so. The nurse practitioner (NP) is a key player in today's healthcare system. NPs are invaluable in helping patients understand diabetes, motivating them to “own” their disease, managing expectations, offering guidance and encouragement, and addressing questions about treatment options. Often serving as the primary care provider, the NP can help both the patient and referral consultants to develop an understandable, unified, and safe treatment plan. Utilizing the resources of the healthcare team, the NP can also make appropriate referrals to other healthcare professionals to ensure efficient, effective, and comprehensive care.

Previous articles in this supplement have discussed the role of NPs in the diagnosis and early management of patients with type 2 diabetes (Robertson, 2012), and explored treatment options and practical considerations at various stages of the disease (Kruger, 2012; Spollett, 2012; Tierney, 2012). In this article, I discuss the role of the NP as the patient's collaborator in maximizing satisfaction with treatment as patients take the lead in managing their diabetes. My goal is to provide a narrative based on many years of personal experience that complements the preceding papers and offers insights into day-to-day diabetes management provided by NPs. While the other papers in this supplement provide evidence-based guidance on conventional aspects of diabetes diagnosis and pharmacotherapy, I hope to offer supportive anecdotal information that ensures a holistic appreciation of the subject and recognizes the value of the personal relationships NPs have with their patients.

The patient's world

Although diabetes management and education are the focus of every diabetes consult, diabetes is only one aspect of a patient's life. When considering ways to improve the treatment experience, it is important to take a broad perspective, considering the patient's job, family life, relationships, etc., as these affect their outlook and attitudes toward treatment. Sometimes these areas need to be addressed directly before a typical diabetes treatment plan may begin. A helpful opening question might be “What is the biggest challenge for you right now in dealing with your diabetes?” This can facilitate an understanding of what is most important to the patient at that moment, which in turn can help achieve the desired outcomes. While the patient's priorities may be very different from those of the clinician, understanding the patient's perspective is important in order to meet their needs. Although NPs often know a great deal about the technical aspects of diabetes management, treatment is unlikely to be effective if the patient is not involved in developing and working toward the goals.

Motivational interviewing (MI; Rollnick, Miller, & Butler, 2007)—a process in which the clinician, using listening and empathy, explores the patients’ motivations and guides them to change—can help patients modify their behavior by offering a strong and supportive patient–provider relationship. One key to MI is to resist the “righting reflex” or attempts to “fix” things and, instead, help the patient to identify solutions and ways to achieve change. Another paradigm for the patient–provider relationship is “coaching,” whereby the patient is considered the driver of a collaborative relationship, while the NP plays a supporting role in facilitating change. Coaching recognizes that many cognitive and practical stages are necessary for meaningful change to occur, and that the NP can facilitate these by approaching the clinical encounter using communication strategies consistent with the coaching model (Hayes, McCahon, Panahi, Hamre, & Pohlman, 2008). Many of the strategies I discuss in this article, including those related to encouraging and motivating the patient, are consistent with the coaching paradigm, in which the alliance between patient and NP is key to improved outcomes.

The motivational support provided by NPs includes explaining to patients how lifestyle choices—such as exercise or self-monitoring of blood glucose (SMBG)—can help them meet their goals. For example, when a patient understands what SMBG readings mean, when they should test, and how to use the results to make behavioral changes, they can use the readings to improve their glycemic control and well being, and reduce long-term complications. They also feel more motivated to make the lifestyle changes necessary to achieve their goals.

One important consideration when counseling patients is that their goals for treatment do not always match those of the healthcare provider. For treatment to be successful, the healthcare provider needs a clear picture of each patient's goals, and the potential barriers to achieving them. For example, we may know that a patient needs to lose weight to improve their diabetes control. The patient is probably also aware that he or she is overweight but, rather than simply telling them to lose weight, explaining the benefits of weight loss (e.g., improved blood glucose control, potential for reduced medication, cardiovascular benefits, generally feeling better, etc.), and providing tools to help them achieve this goal, as outlined later in this article, can be more effective. This can be followed by MI to explore which weight-loss methods might work for each particular patient.

Tips for improving the treatment experience for patients with type 2 diabetes

  • Nurse practitioners (NPs) play a key role in supporting patients’ diabetes education, motivation, confidence, and self-management skills.
  • It is important to consider the patient's job, family life, relationships, etc., when developing a management plan: all of these affect their outlook and attitudes toward treatment.
  • To commit to a management plan, patients need to understand and be involved in setting treatment goals, appreciate why tests are needed and what results mean, and understand how improved glucose control can improve long-term health.
  • By explaining the rationale, mode of action and likely effects of medications, and offering practical guidance, NPs can help patients understand and commit to treatment.

Addressing common treatment-related problems

Treatment-related side effects, especially weight gain and hypoglycemia, are a major concern for patients and affect treatment preference and satisfaction (Hauber, Mohamed, Johnson, & Falvey, 2009; Marrett, Stargardt, Mavros, & Alexander, 2009). Given that over 80% of people with type 2 diabetes are overweight or obese (Smyth & Heron, 2006), weight gain, or fear of weight gain, can reduce treatment satisfaction (Hauber et al., 2009; Marrett et al., 2009) and deter patients from taking certain medications or intensifying treatment (Odegard & Capoccia, 2007; Pi-Sunyer, 2009). The presence and severity of hypoglycemic symptoms is associated with lower health-related quality of life and patients who experience hypoglycemia often develop a fear of future hypoglycemia too (Alvarez-Guisasola, Yin, Nocea, Qui, & Mavros, 2010; Marrett et al., 2009). Selecting treatments that minimize weight gain with a low risk of hypoglycemia—and therefore reduced risk of inducing long-term hypoglycemic unawareness—can help patients feel more optimistic about treatment and motivate them to continue taking their medication.

Lifestyle modifications

People with diabetes benefit from the support and guidance of NPs in making lifestyle modifications that include increased physical activity, weight loss, and improved eating habits. However, achieving these changes for a lifetime is not always easy. MI can help patients to explore ways they may be able to change their lifestyle to improve diabetes control as well as lose weight, if appropriate.

Practical advice on diet and regular exercise helps patients take those first important steps toward achieving their treatment goals. In this endeavor, attention to small details, such as the way suggestions are worded, can make a difference. For example, patients are often relieved when NPs do not use the word “diet” because traditional diets are difficult to maintain over the long term, such dieting is often temporary and followed by a return to old habits, with consequent weight gain. Instead, smaller, lasting changes can produce more enduring results and here NPs can offer practical strategies to help improve eating and exercise habits and facilitate weight loss (Table 1). First, I encourage patients not to eat out of the bag: often the only sign of having overeaten is when the bag is empty. Second, as much of our eating is driven not by hunger but by habit, stress, boredom, or comfort, I encourage patients to become more aware of why they are eating. To do this, I propose that, when eating, they do nothing besides eat: no TV, no reading, no telephone calls. This helps them focus and reduces the likelihood of overeating because of distractions. Smaller plates can help limit serving size as we have a tendency to fill our plates and eat everything on them: many of us have been conditioned since childhood to “clean our plates.” When serving dishes are kept within reach of the table, it is easy to take a second helping or pick at food because it is in front of us. Instead, I suggest that food is served and kept in the kitchen to reduce the tendency to eat more. When eating out, portions served are usually larger than needed; it is helpful to put some food aside “to go” before starting the meal, to reduce the tendency to finish it all. Making gradual, achievable reductions in food intake feels more manageable than trying to lose a large amount of weight, and allows patients to adapt to healthy eating habits that they can maintain for life.

Table 1
Table 1:
Practical advice to help patients improve eating and exercise habits

Guidance on physical activity and exercise can give patients the encouragement they need to make positive, lifelong changes. There is a major psychological component to exercise and difficulty following a planned activity schedule can lead to negative self-thinking, poor self-esteem, and feelings of failure. Indeed, many people do not even begin exercising because they believe they do not have enough time and do not want to “fail.” It is helpful to explore possible activities that the patient could do at home each day. Setting up a regular exercise “date” with a friend can make exercise more enjoyable and tends to make people feel accountable to their exercise “buddy,” which can strengthen their commitment. Keeping goals small and achievable can help patients sustain their efforts by achieving success and building on these goals. One of the most effective strategies is what I call the “5-minute rule”: I encourage patients to do 5 min of exercise a day, 7 days a week. This is not the ideal length of time, but it is more than many people are doing at the outset. By encouraging 5 min every day, patients can get started, which is often one of the biggest barriers to exercising; once started, they can always do more than 5 min. I encourage clinicians to try this for themselves and learn both the challenges and benefits of daily exercise. It is also helpful to look for and highlight signs of progress. If the patient only does 5 min of exercise on 4 days of the week, encourage them to see this as positive progress, not as missing 3 days but as succeeding on 4 days. Another way to encourage activity is to suggest wearing a pedometer. Setting a target to walk an increasing number of steps per day can be motivating. Consider asking the patient to call your office weekly with their total steps for that week as a means to help motivate them to achieve that goal. Affirm any step in the right direction, however small, to help encourage each patient's progress. Small steps over time lead to long-term improvement. For some patients, particularly those with children who may also be at risk of diabetes, it is worth emphasizing that exercise sets a great example for their children. This is one of the best ways to help children lose weight and encourage a lifetime of healthy exercise habits.

Self-monitoring of blood glucose

SMBG is recommended in clinical practice guidelines as a valuable self-management tool for patients who take insulin (American Diabetes Association, 2011). Its benefits and role in noninsulin-treated patients continue to be debated (Clar, Barnard, Cummins, Royle, & Waugh, 2010; Davidson, 2010) but the key is to help patients use SMBG as a tool to make changes in their eating and exercise habits. Often patients come to appointments with a list of blood glucose readings: daily fasting glucose levels that are all similar, or readings taken at different times of the day. Unfortunately, these lists do not help the NP or the patient to understand their diabetes, or enable the NP to provide guidance on what changes to make. The purpose of glucose testing should be to help patients evaluate and change their behavior; as such, the glucose meter is a feedback tool, like a speedometer in a car, which makes the effects of behavior visible. One way to foster an understanding of the relationship between food (or physical activity) and blood glucose readings is through “paired” glucose readings. Performing paired glucose readings involves patients doing a “before” and “after” test before and after a meal, snack, or exercise. Paired readings give immediate feedback that can be used to make changes. If the two glucose readings are nearly the same, even if they are higher than ideal, the patient can see that the meal/snack/activity did not have a pronounced effect on their blood glucose. If the postprandial reading is a lot higher than the preprandial reading, the patient can learn to understand which food had the hyperglycemic effect so it can be eliminated at a future meal. There is no set number of tests per day or times in the day when the patient should perform SMBG; home glucose monitoring should be individualized to provide the information each patient needs to make the necessary changes in their eating and activities.

NPs can also help by identifying which blood glucose meters are “preferred” by different insurance plans. Typically, one or two meters are “preferred” on every insurance plan and by advising patients which these are, and becoming familiar with how they work, NPs can help patients simplify glucose testing and keep costs manageable as “preferred” meters, and/or associated test strips, may cost less. Certain “generic” or store-brand meters with test strips are priced as low as 40% below the major name brands and this can be especially beneficial for self-paying patients. Many meters available now do not require coding, which eliminates one potential error that patients can make. Taking a few minutes to teach the patient how to use a glucose meter at the first visit after diagnosis can help dispel fears, instill confidence, and encourage monitoring. With a little practice, teaching patients how to perform a glucose test takes only 5 min and helps them to realize that there is very little pain associated with the process. Keeping sample meters in the office provides the opportunity to give patients a meter to take home at that first visit. It is then advisable to schedule a follow-up appointment 2 weeks later to review the information obtained by the patient through home monitoring and the effects obtained through lifestyle modification based on paired glucose readings. When paired readings are reviewed at this time, patients almost always have an improved understanding of what raises their blood glucose and show records indicating a trend of reduced blood glucose levels.

Oral agents

Patients with type 2 diabetes may be confused by the wide range of oral antidiabetic drugs (OADs) and their mechanisms of action. The classes of OAD used to treat type 2 diabetes include those that stimulate insulin secretion from beta cells (sulfonylureas [SUs], meglitinides, or “glinides”), improve insulin-mediated glucose uptake (metformin, thiazolidinediones [TZDs]), reduce hepatic glucose output (metformin, TZDs), decrease glucose absorption from the gut (alpha-glucosidase inhibitors), and delay the degradation of endogenous incretin hormones (e.g., dipeptidyl peptidase-4 [DPP-4] inhibitors: sitagliptin, saxagliptin, and linagliptin). These agents have been discussed in detail in other parts of this supplement (Tierney, 2012). NPs can facilitate understanding of oral medications by including on the prescription itself the reason for taking the medication, for example, “take 1 po bid for diabetes.” An explanation of how each medication works and why it is given, as well as any side effects that can be expected, can enhance the patient's understanding and willingness to take it. Reassurance that choice of medication is individualized may also engender trust and a desire to commit to treatment; for example, overweight patients can be reassured that the most suitable therapy for their needs is one that will not cause weight gain. Medication should be initiated at a low dose and titrated upwards according to glycemic efficacy and adverse effects, changing one medication at a time. It helps to discuss medication choices and dose changes throughout this process, as well as identifying when a medication or strategy is no longer effective and treatment intensification is necessary. It is particularly important to explain that the need for additional medication over time is a natural consequence of the progressive nature of type 2 diabetes and not necessarily an indicator of the patient's failure. A written instruction sheet or treatment plan that reviews the medications or changes, as well as behavioral goals, can be helpful so that the patient can share it with family or use it to consolidate the wealth of information covered in an office visit.

When medications are started it is important to reinforce the benefits of continued lifestyle changes and remind patients that medications are not a replacement for, but rather an addition to, lifestyle improvements. Patients can be encouraged by the fact they may be able to stop a medication if weight loss or lifestyle modification leads to improved metabolic control.

Injected agents

GLP-1 analogs

NPs play an important role in educating patients about new diabetes treatments, such as the injected glucagon-like peptide-1 (GLP-1) analogs exenatide (Byetta®; Amylin Pharmaceuticals Inc., San Diego, CA, and Eli Lilly & Co, Indianapolis, IN), and liraglutide (Victoza®; Novo Nordisk A/S, Bagsvaerd, Denmark). When the clinician sees a useful role for a GLP-1 analog, it may be introduced as another option to help achieve patient goals. It is important to describe the mechanism of action of this class of agents: increased pancreatic insulin secretion in response to carbohydrate ingestion, reduced hepatic glucose output, and delayed gastric emptying. Understanding how these agents work helps patients understand how they lead to satiety and reduced food intake. Explaining the “side-effect” of weight loss sometimes gains patients’ interest as well. Some patients are hesitant to start an injected therapy, either because of fear of injections or because of associations with insulin, which some see as an indicator that they are in the late stages of diabetes. As explained earlier, taking a few minutes to help patients try an injection in the office can engender confidence and help overcome fear of injection when it becomes apparent that it is a simple and relatively painless process.

Exenatide is injected twice daily within 1 h before morning and evening meals (it should not be given after meals). It comes in a 5-μg and 10-μg dose pen and patients usually start on 5 μg and continue this for at least a month before increasing to the 10-μg dose, if needed. The timing restrictions with the current formulation of exenatide can present a challenge. For patients who have difficulty remembering to take the second dose of exenatide with supper, or injecting within an hour before meals, liraglutide may be a more suitable alternative as it requires only once-daily dosing and need not be given with meals, although it should be taken consistently at the same time each day. Liraglutide also has a delivery system that allows the patient to titrate the dose very gradually, which can improve tolerability. The manufacturer recommends starting at 0.6 mg per day and increasing to 1.2 mg per day after a week. From there, the patient can increase the dose to 1.8 mg if needed. The liraglutide pen is unique in that there are 10 “clicks” as you turn the pen dial between each of the three recommended doses. To titrate gradually, which can help reduce or even eliminate the nausea sometimes associated with starting GLP-1receptor agonists, I suggest patients begin with one click (or 1/10 of the 0.6-mg dose) on the first day and increase by one click each day such that after 10 days they have reached a dose of 0.6 mg per day. They can continue increasing the dose by adding a click each day, up to the 1.8-mg dose if needed. If nausea occurs, the current dose can be maintained for a few days and, when nausea diminishes, a gradual increase can be continued; nausea usually decreases with continued use. This slow dose titration has increased tolerability and reduced adverse effects in many of my patients. I should emphasize that these recommendations come from my personal experience and not from the manufacturer's product label.

After starting an incretin analog, it can be useful to schedule a follow-up visit in a month to ensure the patient is doing well and to evaluate side effects. Consider checking A1c prior to starting treatment and 1 month after initiation to see if the incretin analog is lowering glucose levels. Although it provides a 3-month glycemic average, the average is weighted toward the most recent month. If A1c is not improving, consider a change in the treatment regimen. Assess for nausea as well as for weight loss at the 1-month follow-up visit.

Once-weekly exenatide will likely soon be available, allowing the patient to inject only once per week. Two potential concerns with this once-weekly treatment would be, first, that adverse reactions could persist longer than with the twice-daily formulation and, second, that patients would have to remember to take their medication just once a week. For some patients, this could be more challenging than remembering to take medication every day.

Insulin

The introduction of incretin analogs may allow some patients with type 2 diabetes to delay or avoid initiating insulin to achieve glycemic control. Nonetheless, for some, insulin may be necessary. Despite evidence that starting insulin in a timely manner improves outcomes, including quality of life (Lee et al., 2010), among patients whose diabetes is poorly controlled with oral agents alone, patients are often reluctant to initiate insulin. A large number of reasons for this have been identified, including fear of needles and injection pain, feelings of personal failure in managing diabetes effectively (Peyrot et al., 2005), fear of hypoglycemia, concerns about weight gain, lack of confidence in managing complex self-injection regimens, perception that insulin therapy is permanent and imposes lifestyle restrictions, and social stigma associated with injecting in public (Choe & Edelman, 2007; Karter et al., 2010; Meece, 2006). Many people also know someone who experienced a serious complication after starting insulin and this may cause the patient to assume, incorrectly, that insulin was the cause of the adverse outcome. For example, if a relative with long-standing, poorly controlled diabetes had an amputation or other complication after starting insulin, the patient may associate the adverse outcome with starting insulin rather than understanding it to be the result of longstanding poorly controlled diabetes. Such barriers hinder initiation or continuation of treatment and impair glycemic control and psychological well being (Fu, Qiu, & Radican, 2009; Peyrot, Rubin, Kruger, & Travis, 2010; Rubin, Peyrot, Kruger, & Travis, 2009).

NPs play an important role in explaining the rationale for using insulin, exploring patients’ concerns, and dispelling any myths and misconceptions they may have (Meece, 2006). Explaining that the newer insulin analogs and pen-type delivery devices overcome many of the drawbacks of conventional insulin can make the transition to insulin easier. Among the many advantages of the newer insulin analogs are a more physiological time–action profile, which reduces hypoglycemia and offers considerable flexibility in dosing, especially around mealtimes (Choe & Edelman, 2007). Ultralong-acting insulins that can be used in combination with rapid-acting analogs further reduce hypoglycemic risk (Birkeland et al., 2011). It is important to appreciate that the approach taken when counseling patients, and the way information is presented, can strongly influence acceptance of insulin therapy. In this regard, it may help to tell patients with type 2 diabetes that insulin need not be a lifelong medication: if glycemic control improves with weight loss and lifestyle changes, insulin can sometimes be discontinued.

There are several practical steps that NPs can take to support successful insulin initiation. Providing support for patients to perform their first insulin injection in the office by using samples of basal insulin (glargine and detemir) builds confidence when patients realize that insulin injection is easier and less painful than they may have expected. Based on my own clinical experience, I advise that patients with poorly controlled type 2 diabetes start basal insulin at a low dose, 10 units per day, and gradually increase the dose themselves to achieve an agreed fasting blood glucose (FBG) target (80–120 mg/dL). One strategy is to increase the dose by 4 units/day every 3 days if FBG is >200 mg/dL or by 2 units/day every 3 days if it is <200 mg/dL but still above the desired goal. Dosing is discussed in more detail in other articles in this supplement (Kruger, 2012; Spollett, 2012) and readers should refer to these for additional dosing information. It is also helpful to remind patients that the goal of using basal insulin is to improve FBG levels so testing this daily, while making dose increases, provides valuable information on progress toward the FBG goal. Usually many more than 10 units a day are needed to achieve adequate glycemic control, but it is advisable to start low and titrate up slowly to avoid hypoglycemia, and to tell patients that they may need as many as 30–60 units a day or more, depending on their initial A1c and blood glucose levels. Follow up with these patients in 4 weeks and consider checking A1c in 1 month to be sure it is decreasing. Testing fructosamine, also known as glycated serum albumin, may be helpful in assessing progress in lowering overall glycemia over a shorter period of time as it provides a 2-week average glucose level. It is also important to check injection sites, visually and by palpation, at each visit in anyone performing injections (insulin or incretins); if patients have lipodystrophy, medications may not be reliably absorbed and can have a reduced effect on blood glucose.

Insulin may be injected using traditional vial and syringe or an insulin pen. Insulin pens have a number of advantages over vial and syringe, including greater accuracy in dosing, especially when making small dose changes (Pearson, 2010). Some patients find them more convenient and easier to use but they may be more expensive, especially for cash-paying patients, and are not covered by some payers unless the patient has documented visual impairment. NPs should discuss with their patients the features and benefits of the different insulin delivery devices to help them select the one most appropriate to their needs (Valentine & Kruger, 2010).

Financial aspects of care

In the United States, lack of insurance coverage and high copayments can prohibit patients from using certain diabetes medications and/or taking them as prescribed, and can increase healthcare utilization and lead to less favorable health outcomes (Colombi, Yu-Isenberg, & Priest, 2008; Gibson et al., 2010). When deciding on a treatment plan for individual patients, it is important to take into account their insurance coverage. Some health insurance plans have achieved improved medication adherence by restructuring their pharmacy benefits and placing all antidiabetic drugs in the lowest copayment tier, substantially reducing drug costs for patients (Berger, 2007). These changes were also associated with reductions in other healthcare costs and annual pharmacy costs.

Many medications for diabetes are now on the $4.00 plans at pharmacies such as Wal-Mart. Sometimes adding an incretin analog (˜$300–400/month) may not cost much more than other treatment options, and may help the patient lose weight and feel better. For example, the monthly cash price of insulin at a dose of 100 IU per day (approximately three 1000-IU vials per month, amounting to a monthly cost of US$360) is similar to the monthly cost for exenatide.

Conclusions

Type 2 diabetes is a chronic condition that can be successfully self-managed on a daily basis by patients who are equipped with the motivation, skills, and knowledge to do so. The NP can be a key player in sharing information and prescribing medications but, even more importantly, NPs play an essential role in motivating their patients to become active participants in their diabetes management. Active engagement of the patient using techniques that help motivate and encourage lifestyle changes and shared decision making will help the patient to achieve improved diabetes control.

Acknowledgment

The assistance of Watermeadow Medical Inc, New York, NY, USA, funded by Novo Nordisk Inc, Princeton, NJ, USA, in preparing this article is gratefully acknowledged.

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Keywords:

Nurse practitioner; diabetes

© 2012 John Wiley & Sons, Inc