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Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really know HOW patients are injecting?

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Page 1: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Injection Techniques Questionnaire (ITQ) WorldWide Results

2014-2015

How can we give proper guidelines until we really know HOW patients

are injecting?

Page 2: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Background

Objectives:

• To survey Insulin Injectors widely and deeply (many patients, many patient types, many

countries)

• To understand every aspect of Insulin Injection, from A to Z

• To obtain the patient’s own view and confirm/test it with the simultaneous view of

his/her HCP

• To go beyond the physical process to the psychology, the challenges, hurdles, benefits

Methodology:

• Self-administered questionnaires completed by patients

• An HCP evaluation during the same visit which includes physical exam, inspection of

devices and questionnaire

2

Page 3: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Background – (continued)

Sample:

• 13,298 subjects from 42 countries

• Inclusion Criteria – Patients injecting insulin for a minimum of 6 months.

Parents and caregivers who give injections were also allowed to

participate

Timing:

• Feb 2014-June 2015

3

Page 4: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

4th in a series of ITQs

1. 1995 First ITQ

developed and administered in Finland

by DM Nurse Tuula Maria Partanen

2. 1999 Second ITQ

administered in 7 European countries to 1001 patients

3. 2008 Third ITQ

administered in 16 countries WW to 4352 patients

4. 2014-5 Fourth ITQ

administered in 42 countries WW to 13,289 patients

4

Page 7: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Countries, Centers, Patients

7

COUNTRY NUMBER

CENTERS

NUMBER SUBJECTS

USA 49 304

Canada 14 329

Russia 7 173

South Africa 4 162

Greece 2 30

Netherlands 4 83

Belgium 9 165

France 21 254

Spain 9 203

Italy 15 358

Switzerland 7 84

Austria 6 116

UK 61 499

Denmark 1 36

Sweden 3 104

Poland 4 111

Page 8: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Countries, Centers, Patients

8

COUNTRY NUMBER

CENTERS

NUMBER SUBJECTS

Germany 26 480

Peru 1

Mexico 5 138

Argentina 3 75

Brazil 5 255

Chile 1 21

Colombia 1 25

Venezuela 1 25

Malaysia 2 51

Australia 7 95

Indonesia 7 144

Philippines 3 77

Singapore 2 25

Japan N/A* 1342

S. Korea 9 180 *In Japan the ITQ was not administered center by center.

Instead it was Internet-based. Patients from many centers all over the country participated.

Page 9: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Countries, Centers, Patients

9

COUNTRY NUMBER

CENTERS

NUMBER SUBJECTS

China 21 3853

Turkey 56 1376

India 20 1011

Ireland 3 45

Finland 4 103

Czech Republic 11 163

Nicaragua 1 16

Ecuador 1 23

Taïwan 1 100

Saudi Arabia 11 515

United Arab

Emirates

5 115

TOTAL 423 13,289

Page 10: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Who filled out the questionnaires?

10

IDENTITY N %

Self-injecting adult (18 years old or older) 8627 90.5

Self-injecting adolescent (13-17 years old) 469 4.9

Self-injecting child (< 13 years old) 226 2.4

Parent who gives injections to child 209 2.2

TOTAL 9531 100.0

Page 11: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What type of DM did the patients have?

11

N %

T1DM 2790 33.8

T2DM 5378 65.2

GDM 86 1.0

Total 8254 100.0

Page 12: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

HbA1c by type of DM?

p <0.000

HbA1c

Mean SD N

DM type

T1DM 8.49 1.9 2600

T2DM

8.48 1.9 4839

GDM

6.17 1.3 80

Page 13: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Descriptive Statistics

13

N Mean SD Minimum Maximum

AGE 13225 51.9 18.1 1 95

BMI 12806 26.6 6.2 11.1 70.4

YEARS with DM 9197 13.2 9.7 1 78

AGE DM DIAGNOSED 12737 39.9 17.2 0 90

YEARS ON PILLS 6607 8.3 7.2 0 76

YEARS ON INSULIN 8242 8.7 8.9 0 78

Female 50.3% Male 49.7%

N Mean SD Minimum Maximum

HbA1c 7663 8.47 2.139 4 19

Page 14: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Descriptive Statistics

14

N Mean SD Minimum Maximum

DAILY DOSE RAPID INSULIN 1422 27.0 20.7 1 200

DAILY DOSE FAST ANALOGUE 3467 31.9 21.6 1 240

DAILY DOSE NPH 1134 31.6 24.4 1 180

DAILY DOSE BASAL ANALOGUE 4709 27.6 19.5 1 260

DAILY DOSE PRE-MIXES 1796 43.0 25.3 1 252

TOTAL DAILY DOSE INSULINS 7756 48.5 32.4 0 340

40% still on pills 2% also on GLP-1s

Page 15: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What Injection Devices were Used?

15

DEVICE N %

Syringe 1238 9.6

Pen 11070 85.6

Pen + Pump 184 1.4

Pen + Syringe 337 2.6

Page 16: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How many injections were given per day?

16

INJECTIONS/DAY N %

1 1523 16.0

2 2480 26.0

3 1240 13.0

4 3213 33.7

5 735 7.7

6 197 2.1

7 70 .7

>7 71 .7

Total 9529 100.0

Page 17: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Where do patients give their injections?

17

Injection Site %*

Abdomen 90.9%

Thigh 43.0%

Buttocks 13.8%

Arm 31.9%

*percentages add to over 100 because many patients use more than one site

Page 18: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What needle length did patients say they used?

18

NEEDLE LENGTH % 2014

12.7 mm 1.0

8 mm 19.6

6 mm 17.3

5 mm 16.5

4mm 23.1

Don’t know 15.1

Page 19: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How has this changed since the last ITQ?

19

NEEDLE LENGTH % 2014 % 2009

12.7 mm 1.0 5.3

8 mm 19.6 48,6

6 mm 17.3 15,8

5 mm 16.5 21,6

4mm 23.1 0

Don’t know 15.1 7,0

Page 20: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Length of needle (mm)

12,70 8,00 6,00 5,00

Co

un

t

400

300

200

100

0

Device

Syringe

Pen

Needle Length in Second ITQ (1999)

20

Page 21: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What needle length did nurses observe?

21

NEEDLE LENGTH %

as per Nurse

12.7 mm 0.9

8 mm 27.1

6 mm 20.1

5 mm 20.3

4mm 28.1

Don’t know N/A

Page 22: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How does this compare to what the patient reported?

22

NEEDLE LENGTH %

as per Nurse

%

as per Patient

12.7 mm 0.9 1.0

8 mm 27.1 19.6

6 mm 20.1 17.3

5 mm 20.3 16.5

4mm 28.1 23.1

Don’t know N/A 15.1

Page 23: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What needle gauge did nurses observe?

23

NEEDLE GAUGE %

as per Nurse

29 2.9

30 13.1

31 46.1

32 34.7

33 0.2

Page 24: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

90% of patients claim they rotate, but do they do it correctly?

24

How they Rotate %

I move back and forth from right side of my body to left 26.7

I move from one injection site to another 20.1

I inject about a finger’s breadth (1 cm) from where I previously injected 17.8

My injections describe a circle around my injection sites 8.5

My injections describe lines across my injection sites. 4.1

Page 25: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

The choices in green below are optimal

25

How they Rotate %

I move back and forth from right side of my body to left 26.7

I move from one injection site to another 20.1

I inject about a finger’s breadth (1 cm) from where I previously injected 17.8

My injections describe a circle around my injection sites 8.5

My injections describe lines across my injection sites. 4.1

Page 26: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What do patients say about Lipos?

26

Do you have any swelling or lumps under the skin at your usual injection

sites that have been there for some time (weeks, months or years)?

Answer N %

Yes 3855 29.0

No 9334 70.2

Total 13189 99.2

Page 27: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How does this compare to the last ITQ?

27

Do you have any swelling or lumps under the skin at your usual injection

sites that have been there for some time (weeks, months or years)?

Answer % 2014 % 2009

Yes 29.0 47.9

No 70.2 52.1

Total 99.2 100

But the question was posed quite differently in 2009:

Have you ever noticed swelling of fatty tissue or small bumps at your injection sites?

Page 28: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

What LH frequency did nurses find on exam by site?

28

SITE EXAM TYPE % lipos

found

ABDOMEN

Visual 17.3

Palpation 21.1

THIGH

Visual 9.8

Palpation 11.2

BUTTOCKS

Visual 2.1

Palpation 2.8

ARM

Visual 11.2

Palpation 13.4

Overall, the nurse found lipohypertrophy in 30.8% of patients

Page 29: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How does this compare to the previous ITQ?

29

Overall, the nurse found lipohypertrophy in 24% of patients in 2009

SITE EXAM TYPE % 2014 % 2009*

ABDOMEN

Visual 17.3 20.7

Palpation 21.1

THIGH

Visual 9.8 15.9

Palpation 11.2

BUTTOCKS

Visual 2.1 6.2

Palpation 2.8

ARM

Visual 11.2 12.3

Palpation 13.4

* Visual and Palpation combined in 2009

Page 30: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do the patients’ reports of lipos match the nurses’ findings?

30

SITE EXAM TYPE % lipos Patients report lipos

at these sites (%)*

ABDOMEN

Visual 17.3 60.0 Palpation 21.1

THIGH

Visual 9.8

12.3 Palpation 11.2

BUTTOCKS

Visual 2.1

1.2

Palpation 2.8

ARM

Visual 11.2

10.2 Palpation 13.4

*percentages don’t add to 100 because patients report abnormalities at several sites (e.g. 7.1% of patients say they have lipos on both the abdomen and thigh)

Page 31: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How often do patients say they inject into lipos?

31

Frequency %

Always 8.3

Sometimes 31.2

Never 60.4

Page 32: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Why do they inject into lipos?

32

Reason %

It’s convenient 11.3

It’s less painful 16.8

Just a habit (I always inject there) 30.8

Don’t know 28.0

Page 33: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Scale used to assess Size of Injection Sites

33

Post Card

Playing Card

Credit Card

Stamp

Page 34: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

34

N Mean SD Minimum Maximum

SIZE ABDOMINAL LIPOS (mm) 1320 44.5 36.1 2 300

SIZE THIGH LIPOS (mm) 487 41.9 36.9 1 300

SIZE BUTTOCKS LIPOS (mm) 54 49.7 52.7 10 350

SIZE ARM LIPOS (mm) 393 35.7 26.5 2 300

Size of Lipos in mm as measured by Nurse (longest dimension)

Page 35: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

For the lipos found by the nurse, was there evidence the patient was still injecting into it? If so, how frequently?

35

Still Injecting into Lipos? N %

Yes 1775 44.0

No 2263 56.0

Frequency %

Every injection 16.7

Frequently (daily) 39.5

Occasionally (weekly) 30.3

Seldom (monthly) 13.5

Page 36: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How long do patients on pens leave needle in skin?

36

Time %

< 5 sec 18.6

5 – 10 sec 45.6

> 10 sec 31.9

I’m not aware of how long 3.9

Page 37: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients reuse their pen needle, and if so, how often?

37

Reuse Needle N %

Yes 6676 55.8

No 5285 44.2

Times %

2 times 30.7

3 to 5 times 39.7

6 to 10 times 16.0

More than 10 times 13.6

Page 38: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How does this compare to syringes?

38

Reuse Needle % Pens

Yes 55.8

No 44.2

Times % Pens

2 times 30.7

3 to 5 times 39.7

6 to 10 times 16.0

More than 10 times 13.6

% Syringes

35.4

44.0

11.4

9.2

% Syringes

38.8

61.2

Page 39: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Why do they reuse the pen needles?

39

Reasons %

Because I did not have another pen needle available 9.2

To save money 23.3

To prevent excess waste (environmental concern) 6.8

For convenience 41.2

Page 40: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How does this compare to syringes?

40

Reasons % Pens

Because I did not have another pen needle available 9.2

To save money 23.3

To prevent excess waste (environmental concern) 6.8

For convenience 41.2

% Syringes

14.5

38.4

6.6

26.1

Page 41: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients find injections painful? If so, how frequently?

41

Have pain? N %

Yes 5045 55.4

No 4069 44.6

Frequency %

Always painful 2.6

Often painful (several times a week) 12.9

Sometimes painful (several times a month) 45.6

Almost never painful (several times a year) 38.9

Page 42: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients see bleeding/bruising? If so, how frequently?

42

Bleeding/

bruising? N %

Yes 5878 60.2

No 3892 39.8

Frequency %

Always .5

Often (several times a week) 7.3

Sometimes (several times a month) 41.5

Almost never (several times a year) 50.8

Page 43: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients see leakage from injection sites? If so, how frequently?

43

Site leakage? N %

Yes 3611 36.9

No 6188 63.1

Frequency %

Always 2.2

Often (several times a week) 13.3

Sometimes (several times a month) 46.4

Almost never (several times a year) 38.1

Page 44: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients see leakage from needle tip? If so, how frequently?

44

Tip leakage? N %

Yes 4267 43.0

No 5659 57.0

Frequency %

Always 6.8

Often (several times a week) 20.2

Sometimes (several times a month) 46.1

Almost never (several times a year) 26.9

Page 45: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients inject through clothing? If so, how frequently?

45

Thru Clothing? N %

Yes 782 8.0

No 9011 92.0

Frequency %

Always 4.2

Often (several times a week) 12.6

Sometimes (several times a month) 24.9

Almost never (several times a year) 58.3

Page 46: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients use cloudy insulin (NPH, N or pre-mixed insulin)? If so, how many times to they roll or tip to reconstitute?

46

Cloudy? N %

Yes 5968 65.5

No 2201 24.1

Number rolls/tips %

2 7.3

3 7.3

4 5.5

5 16.1

10 34.6

15 4.4

20 10.2

Page 47: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Do patients skip injections? If so, how frequently?

47

Skip? N %

Yes 5870 44.7

No 7274 55.3

Frequency %

Often (several times a week) 8.5

Sometimes (several times a month) 35.9

Almost never (several times a year) 55.6

Main reasons given are: I forgot (51.6%)

I didn’t eat (8.8%)

My glucose was too low (7.2%)

Page 48: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Where is insulin stored BEFORE opening? Where AFTER? Is it allowed to warm up before injection?

48

Before N %

Fridge 8566 88.6

Room Temperature 1104 11.4

After N %

Fridge 4131 43.0

Room Temperature 5479 57.0

Warm Up? N %

Yes 4432 56.3

No 3439 43.7

Page 49: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How many persons inject cold insulin (a cause of painful injections)?

49

Warm Up

Yes No

Store Cold after Open

Yes 25.9% 26.7%

No 30.7% 16.8%

Page 50: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

After usage, where do people put their needles?

50

Where Dispose? %

Into a container specially made for used sharps 20.7

Into a home container such as an empty bottle 23.0

Into the rubbish with the cap on 48.1

Into the rubbish without recapping 6.9

I clip off the needle and it stays in the clipper 1.3

Page 51: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Where is the final resting place of the used needles?

51

What do you do with the waste? %

Put it into the rubbish 40.3

Take it to a pharmacist 12.8

Take it to a doctor’s office 6.3

Take it to a laboratory 0.4

Take it to the hospital or clinic 22.1

Take it to a local deposit or collection service 11.0

None of the above 7.1

Page 52: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Who gave the patients their Injection Training?

52

Injection Instructor %

General Nurse 22.9

Diabetes Nurse 46.7

Diabetes Educator 12.3

Doctor (General Practitioner) 5.1

Doctor (Diabetes Specialist) 10.0

Pharmacist 2.0

A representative of the pen or needle

manufacturer 1.0

Page 53: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

How often does the nurse or doctor examine injection sites?

53

Frequency %

Routinely every visit. 28.3

Once a year 12.6

Only if I complain of a problem at a site 20.2

I can’t remember my sites ever being checked 38.9

Page 54: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

When was the last time the patient received instructions on Injecting?

54

Frequency %

Within the past 6 months 37.4

Within the past 6-12 months 17.6

Sometime in the last 1 to 5 years 21.5

Sometime in the last 5 to 10 years 13.5

Never 10.0

Page 55: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Topics Patients DON’T ever remember being trained on:

55

% patients who

can’t remember

being trained

Injection sites (e.g. thigh, arm, buttock, abdomen) 11.6

Skin thickness and appropriate depth of injection 27.2

Length of needle 25.6

How to do a skin lift or “pinch up” the skin 18.2

How long to hold a skin lift or “pinch up” 25.7

Angle of needle entry 16.1

How long to keep the needle in the skin after injection 16.4

Rotating within an injection site 18.4

Prevention of air bubbles (syringe) or proper priming of pen needle 19.7

Mixing insulin in a syringe (for syringe users) 30.3

Re-suspension of cloudy insulin 25.0

Single use of pen needle/syringe 19.0

Safe disposal of sharps (pen needles, syringes) 28.2

Page 56: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Hypoglycemia History in last 6 Months

56

Hypo in last 6 months N %

Yes 5605 57.3

No 4170 42.7

Total 9775 100.0

Frequency needed 3rd party assistance with hypo N %

None 3563 57.4

1 to 2 times 1502 24.2

3 to 5 time 587 9.5

More than 5 times 559 9.0

Total 6211 100.0

Needed hospitalization for hypo N %

Yes 594 8.3 No 6563 91.7

Total 7157 100.0

Page 57: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Diabetic Ketoacidosis (DKA) History

57

Ever hospitalized for DKA N % Yes 1680 17.4

No 7949 82.6

Total 9629 100.0

Timing of DKA N %

Only at diagnosis of DM 867 49.3

Had DKA, but not within last 6 months 643 36.6

Had DKA within last 6 months 248 14.1

Total 1758 100.0

Page 58: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Frequent hyperglycemia (blood glucose values more than 250 mg/dL [13.9 mM/L])

58

Hyperglycemia often? N %

Yes 4531 47.1

No 5079 52.9

Total 9610 100.0

Frequency of hyperglycemia N %

More than 5 high readings/week 1179 23.8

3 to 5 high readings/week 1306 26.3

1 or 2 high readings/week 1279 25.8

An occasional high reading (less than 4 times/month) 1198 24.1

Total 4962 100.0

Page 59: Injection Techniques Questionnaire (ITQ) WorldWide Results · Injection Techniques Questionnaire (ITQ) WorldWide Results 2014-2015 How can we give proper guidelines until we really

Are there persons in the immediate surroundings who might accidentally get stuck with sharps? If so, who?

59

At risk? N %

Yes 1423 14.7

No 8276 85.3

Who? %

Children 23.4

Other family members (e.g. spouse) 39.5

Nurse or other professional 4.6

House keeper or rubbish collector 8.2

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Have any of these people ever gotten stuck? If you’re a risk to others, why?

60

Already stuck? N %

Yes 410 8.6

No 4379 91.4

Why? %

I don’t use devices that prevent injuries to others (safety devices) 22.9

I don’t have appropriate disposal containers for my used sharps 35.5

Used sharps are sometimes left in places where others might get stuck 19.1

I’m positive for hepatitis or another blood-borne illness 3.7

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How often were lipoatrophy and redness seen at sites?

61

SITE FINDING %

ABDOMEN

Lipoatrophy 0.6

Redness 3.3

THIGH

Lipoatrophy 0.5

Redness 2.8

BUTTOCKS

Lipoatrophy 0.2

Redness 0.4

ARM

Lipoatrophy 0.4

Redness 3.6

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On nurse’s inspection was the patient rotating sites? If so, was the rotation done correctly?*

62

Rotates? N %

Yes 6889 83.9

No 1318 16.1

Correctly? N %

Yes 5643 70.6

No 2350 29.4

*Correct site rotation is defined as always injecting

at least 1 cm from a previous injection

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On mock injection did the nurse observe the patient lifting a skin fold? If so, was it done correctly? Was it released appropriately?

63

Ski fold? N %

Yes 5257 63.7

No 2996 36.3

Correctly? N %

Yes 4028 75.0

No 1340 25.0

When released? %

Once the needle is in the skin 18.5

Once the insulin is totally injected 33.5

Once the insulin is injected and the needle is removed from the skin 48.0

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Frequent Unexplained Hypoglycemia

‘Hypoglycemia’ is defined as the occurrence of ≥1 symptom of low sugar (e.g., palpitations, tiredness, sweating, strong hunger, dizziness, tremor) and a confirmed blood glucose meter reading ≤60 mg/dL (3.3 mM/L). ‘Frequent unexplained hypoglycemia’ is defined as hypoglycemia occurring one or more times weekly in the absence of a definable precipitating event such as a change in medication, diet or activity.

How often were patients found by the nurse to have FREQUENT UNEXPLAINED HYPOGLYCEMIA?

64

HYPOS? N %

Yes 1580 19.4

No 6558 80.6

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Glucose Variability

‘Glycemic variability’ is the presence of blood glucose oscillations from less than 60 mg/dL (3.3 mM/L) to more than 250 mg/dL (13.9 mM/L) at least 3 times a week in an unpredictable and unexplained fashion and evidence of such a pattern for at least the previous 6 months

How often were patients found by the nurse to have GLUCOSE VARIABILITY?

65

VARIABILITY? N %

Yes 2872 35.4

No 5251 64.6

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Who was the HCP who performed the ITQ?

66

Professional %

General Nurse 17.1

Diabetes Nurse 56.1

Diabetes Educator 22.8

Doctor (General Practitioner) 1.0

Doctor (Specialist) 3.0

Almost all were aware of the New Injection Recommendations and had changed their practice based on them

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What areas of practice did these HCPs change based on the New Recommendations?

67

TOPIC % WHO CHANGED

THEIR PRACTICE

Psychological care of patients who inject 53,3

Therapeutic injection technique education 71,8

Injection site care 69,3

Insulin storage and suspension 48,8

Injecting process 62,1

The proper use of pens 53,2

The proper use of syringes 33,2

Absorption rates of differing insulin types 47,7

Needle length for children or adolescents 47,5

Lifted skin folds 59,2

Lipohypertrophy 62,7

Rotating injection sites 65,1

Bleeding and bruising at injection sites 37,9

Injections in pregnancy 33,3

Safety needles 43,0

Disposal of injecting material 49,0

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Comparisons from First through Third ITQ

68

Parameter 1999-2000 2008-2009 2014-2015

Number of Participants 1002 4352 13,289

Number of Participating Centers 22 171 423

Number of Countries 7 16 42

Age of Participants (mean in years) 47.0 48.4 51.9

Duration of therapy (mean in years) 14.7 13.9 13.2

BMI of Participants (kg/m2, mean) 26.5 27.3 26.6

HbA1c (%, mean) 8.0 8.1 8.5

Participants taking 4 or more injections/day 46.2% 43.9% 44.9%

Participants using Insulin Pen 78.8% 92.3% 89.6%

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Comparisons from First through Third ITQ

69

Parameter 1999-2000 2008-2009 2014-2015

Participants using 8mm needle 55.0% 48.6% 29.2%

Participants using needle <8mm 9.5% 44.4% 70.8%

Participants using needle >8mm 35.5% 7.0% 0.9%

Participants injecting into Abdomen 85% 88% 90.9%

Participants injecting into Thigh 69% 59% 43.0%

Participants injecting into Buttocks 24% 16% 13.8%

Participants injecting into Arm 34% 29% 31.9%

Participants injecting using pinch up 69.4% 72.9% 63.7%

Rotation of injecting sites 38% 91% 83.9%

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Comparisons from First through Third ITQ

70

Parameter 1999-2000 2008-2009 2014-2015

Prevalence of occasional bleeding or

bruising 62% 61% 60.2%

Prevalence of lipohypertrophy 29% 48%* 30.8%**

Times single needle used (mean) 3.3 3.6 ***

Injections sites checked on every office visit 22% 36% 28%

Needles disposed into rubbish directly 47% 38% 55%

Disposal into rubbish without recapping 22% 3.5% 6.9%

Participants desiring more education on

injection technique 70% 25% ***

*patient reported (nurse found lipohypertrophy in 24%)

**nurse found

***question posed differently