Proper insulin injection technique is important for optimal glycaemic control, yet patients with diabetes often inject insulin incorrectly. Previous studies identified common errors in insulin injection in Canada, and this article seeks to evaluate the current insulin injection technique practices among patients and explore the effectiveness of feedback and education in improving their technique.
Methods
The study recruited 147 patients and 16 physicians across Canada to gather insights into current insulin injection practices and education gaps. Eligible patients were people living with diabetes who inject insulin using an insulin pen and pen needles. Eligible physicians, who were unsupported by diabetes educators, completed a practice assessment survey and selected 10 eligible patients to complete a baseline assessment survey. During the patient visit, if an error in the patient’s technique was identified, a pop-up knowledge transfer (KT) prompt would appear, providing feedback and information on best practices at the point of care. Follow-up surveys were completed 1–3 months later.
Results
Physicians reported facing barriers to providing education and feedback, including lack of time and personnel, and lack of effective educational material. Patients demonstrated modest improvements in some injection technique domains at their follow-up visit, including injection force factors, time the needle was held in the skin, pen needle reuse, injection area size, and injection angle. The most common initial mistakes by patients were selecting an area smaller than recommended and not paying attention to the injection force. At the second visit, patients reduced an average of one error in their injection technique.
Conclusion
Results showed that basic feedback by their physician during one visit could exert moderate improvements on patients’ injection technique. Proper injection technique is critical for diabetes management, and incorporating targeted ongoing education and support can significantly enhance physician practices, ultimately reducing risks and improving outcomes.
Proper insulin injection technique is important for optimal diabetes control.
Previous studies have observed that incorrect insulin injection technique is prevalent among patients with diabetes.
The study aimed to evaluate current insulin injection technique practices among patients with diabetes. The hypothesis was that providing feedback and education at the point of care to patients would improve their insulin injection technique.
What was learned from the study?
Patients demonstrated modest improvements in certain injection technique domains after receiving feedback and education from physicians during one visit.
The study showed that basic feedback and information provided at the point of care could lead to moderate improvements in insulin injection technique.
The study underscores the need for effective educational materials and resources, as well as addressing barriers such as lack of time and personnel faced by physicians in providing education and feedback.
Introduction
Proper insulin injection technique is important for people living with diabetes, yet many struggle to inject insulin correctly [1, 2]. Inadequate technique can lead to inconsistent blood glucose levels, pain and discomfort during the injection process, lipohypertrophy (LH), and increased risk of infection [3‐5]. To help prevent these issues and ensure optimal diabetes management, it is essential for patients and healthcare providers to learn and reinforce proper injection technique.
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In Canada, a previous survey identified common errors in injection, including injecting with too much force, improper injection site selection and site rotation, not holding the pen needle in the skin long enough, pen needle reuse, incorrect use of a skin lift, use of longer pen needle than required, and insulin injection into lipohypertrophic tissue [2, 6]. Similar errors have been identified worldwide [3, 7].
Access to diabetes education in Canada varies because of differences in provincial health policies, geography, and social determinants of health [8]. However, providing education and feedback to patients can significantly improve their injection technique and diabetes management [9‐12]. Better access to education resources is necessary to enhance diabetes control and outcomes [13‐16]. For instance, the latest Forum for Injection Technique (FIT) recommendations were developed in Canada in 2020 as a blueprint for best practice in injection technique for all diabetes care providers [6, 17].
The FIT recommendations were created by the Canadian FIT Board and reviewed by an expert committee of diabetes educators to provide advice on the proper use of insulin devices, as well as adequate insulin injection procedures. These include in-depth, evidence-based best practice recommendations, such as information about proper syringe selection, recommended application angle and force, as well as guidance on injection area selection, injection site rotation, and many other important practices that aim to improve the health outcomes of people with diabetes who require insulin injections [17]
By utilizing insights from a previous survey that identified common technique errors in Canada [2], this article seeks to evaluate the current insulin injection technique among clinical practices in Canada that do not have a certified diabetes educator and highlight areas that need improvement. We explore the effectiveness of point-of-care feedback and education about best practices in improving patients’ technique, to provide insight into the current state of insulin injection technique practices with the goal of supporting diabetes care for patients in Canada.
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Methods
Study Design and Participants
This study recruited 16 physicians across Canada, including general practitioners and endocrinologists. The inclusion criteria for physicians were insulin initiators not supported by a diabetes educator. Physicians documented survey responses for 147 eligible patients, who were people living with type 1 or type 2 diabetes who inject insulin using an insulin pen and pen needles. Patients with gestational diabetes and those unable or unwilling to provide informed consent were excluded from the study.
One practice-based and two patient-centred surveys were developed to gather insights into current injection practices and educational gaps and opportunities (Supplementary Material). All patient surveys were completed at the point of care and the data was entered into a custom online platform and database.
Procedure
Each physician was asked to complete a practice profile survey, which provided information about their practice characteristics, attitudes, and perspectives regarding insulin injection technique. In addition, the physicians were asked to randomly select 10 eligible patients and fill out a baseline assessment survey for each of them that included questions about their injection technique. The survey was conducted at point of care and, if an error in the patient’s technique was identified in the survey, a pop-up knowledge transfer (KT) prompt based on FIT recommendations would be triggered, providing immediate feedback and information on best practices related to that specific item and verbal feedback was provided to the patient (Supplementary Material). Additionally, information related to correct injection technique was provided to the patients alongside their consent form. At their next visit (average follow-up time of 34.7 ± 8.3 days, median 32 ± 2.9 days), the patient completed a follow-up survey to identify any changes to their technique. Visits took place from July to December 2022.
Error Categorization
Figure 1 shows a summary of the possible answers to the survey categorized as optimal on the basis of the FIT recommendations [17].
Fig. 1
Error categorization. Summary of all possible answers related to the patient’s injection technique. Answers considered optimal are shown in green.
The protocol for the Injection Technique Practice Reflective 2.0 study (Pro00062488) was reviewed and approved by the Advarra® institutional review board on May 5, 2022, and adhered to the principles of the Declaration of Helsinki of 1964 and its later amendments, Good Clinical Practice guidelines, and relevant laws and regulations. Advarra®, established in 1983, offers institutional review board (IRB), institutional biosafety committee (IBC), and research quality and compliance consulting services in North America. Prior to participating in the study, written informed consent was obtained from both patients and physicians.
Statistical Software
Data analysis was performed using R version 4.2.1 [18]; details about the specific packages utilized can be found in the Supplementary Material.
Statistical Analyses
Multiple mid-p McNemar tests (with central confidence intervals) were performed to calculate statistical differences between the assessment and follow-up visits. Corrections for multiple tests were made using the discrete Holm correction.
The effect size was calculated using Cohen’s g statistic, which measures asymmetry for dependent (paired) contingency tables. This calculation can be used to help differentiate statistical significance from clinical significance. More details regarding the interpretation of the effect size can be found in the Supplementary Material.
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To assess the pre–post comparison of the number of incorrect responses provided by the patients, a paired sample t test was utilized.
Results
Practice and Patient Profiles
In this study, 16 physicians without access to a certified diabetes educator were recruited, the majority of whom reported seeing an average of more than 40 patients living with diabetes per week (31%). The remaining participants reported seeing 31–40 patients (25%), 21–30 patients (25%), and 10–20 patients per week (19%). Of their patients on insulin therapy, most physicians (62%) reported that 25–50% of their patients were on this therapy, 31% reported less than 25% of their patients were; and 6% reported 51–75% of their patients were. A summary of the practice and patient profiles is presented in Tables 1, 2, 3.
Table 1
Practice characteristics
Number (%)
Region of practice
Ontario
9 (56)
Alberta
2 (12)
Nova Scotia
2 (12)
Saskatchewan
2 (12)
British Columbia
1 (6)
Practice type
Private
10 (62)
Group
6 (38)
Practice size
Small
1 (6)
Medium
2 (12)
Large
13 (81)
Years in practice
5–10
4 (25)
11–15
2 (12)
16–25
4 (25)
> 25
6 (38)
Table 2
Patient demographics
Characteristics (n = 147)
Mean
SD
Minimum
Maximum
Age, years
60.04
13.35
22
86
Duration of diabetes, years
18.03
11.08
0
55
Type 1 diabetes n = 29 (19.7%)
Age, years
46.69
15.82
7
55
Duration of diabetes, years
22.24
13.83
7
55
Type 2 diabetes n = 118 (80.3%)
Age, years
63.32
10.37
29
86
Duration of diabetes, years
17
10.10
0
50
SD standard deviation
Table 3
Years of insulin use
Years using insulin
Number
Percent
< 3 months
4
2.7
3–12 months
11
7.5
1–5 years
49
33.3
6–9 years
35
23.8
> 10 years
48
32.7
Virtual Medicine Practices
When we examined the distribution of in-person versus virtual visits, most participants (38%) reported that less than 20% of their visits were conducted virtually and 31% indicated they conducted between 21% and 40% of their visits online. Of the remaining participants, 12% conducted around 41–60% of their visits virtually, while 6% and 12% conducted 61–80% and over 80% of their consultations online, respectively. The frequency of each type of visit through time can be visualized in Fig. S1.
Physician Perspectives on Injection Technique Education
A visual summary of responses related to perspectives and attitudes from physicians towards patient education on injection technique is presented in Fig. 3. Panels a–g summarize answers to questions related to physician’s practices (n = 16) and panels h and i summarize responses from physicians about individual patients (n = 147). Notably, 44% of physicians mentioned providing the initial training for insulin injection themselves, 25% refer their patients to a diabetes educator, and 30% have either staff or pharmacists provide this training.
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When asked how often they observe how patients deliver their insulin, 50% answered they do it when appropriate based on clinical discretion, 25% at least every 6 months, and 12% reported they never do it. As well, 38% reported only examining the injection site of a patient when clinically appropriate, 19% at least once per year, 19% at least every 6 months, and 6% never do it.
Regarding familiarity with the FIT recommendations, 50% reported not knowing about them, while 12% had heard about them, but had not read them yet. Additionally, 19% reported being familiar with them but not using them, and 19% are familiar and use the recommendations with their patients who inject insulin.
In terms of confidence, 31% of physicians reported being completely confident in discussing a patient’s technique for site rotation, 56% are fairly confident, 6% slightly confident, and 6% reported not being confident at all.
Lack of time, personnel and support, and lack of effective educational material were identified by physicians that do not have a certified diabetes educator as the top three barriers preventing them from educating patients on injection technique.
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Changes in Physician Behaviours
Results regarding changes in physician-related behaviours can be found in Figs. 2 and 3.
Fig. 2
Changes in physician behaviours (assessment vs. follow-up). Results from the pre–post mid-p McNemar tests are shown as mosaic plots. The width of the segments represents the proportion of the total sample for the follow-up results, and the height of the segments represents the proportion of the total sample for the assessment results. The size of the segments is proportional to the sample size for each of the four possible combinations: correct–correct, correct–incorrect, incorrect–correct, and incorrect–incorrect
Fig. 3
Perspectives and attitudes from physicians towards patient education on injection technique. A–G Summary of answers to questions related to physician’s practices (n = 16). H, I Summary of responses from physicians about individual patients (n = 147)
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Lipohypertrophy Assessment Frequency
During the initial questionnaire, the recorded patient responses showed that physicians did an LH assessment at every visit only 23.14% (n = 34) of the time. Of those, 8.84% (n = 13) of the responses showed the same results at the follow-up visit, but 14.3% (n = 21) showed the frequency of LH assessments was reduced. Among the remaining 113 responses, 28.6% (n = 42) showed the physicians increased the frequency of LH assessments from less-than-optimal frequency to the FIT recommended once per visit by the end of the study. Ultimately, 48.3% (n = 71) of the responses indicated there was no change in the frequency of LH assessments, with it being less than once per visit. McNemar mid-p test showed a statistically significant improvement (padj = 0.031) with a medium effect size (Cohen’s g = 0.17).
Taught Injection Site Rotation
Physicians reported almost all patients (96.6%; n = 142) were taught about appropriate injection site rotation during both the assessment and follow-up visits. However, a small number of patients (2.04%; n = 3) were not taught how to rotate injection sites during the assessment visit but were taught about it during the follow-up visit, while two patients (1.36%) experienced the opposite. The small sample size of five patients that experienced a change in physician behaviour may have contributed to the nonsignificant statistical result (padj = 0.624).
Patient Self-Injection Behaviours
Number of Errors and Proportion of Patients Making a Specific Error
The number of errors by each patient at the initial assessment visit were summarized. The result followed the Gaussian distribution, with 7% of the patients making no errors, 5% making one error, 19% making two errors, 33% making three errors, and the remaining 36% of the patients making four errors or more.
Regarding the most common insulin injection technique errors at the initial assessment visit, the most common mistake was made when deciding the size of the injection area, with 73% of patients choosing an area smaller than a postcard. Attention to force was the second most common error, with 61% of the patients stating they did not pay attention to how much force they were applying when injecting insulin, followed by the injection force with just under half of patients making an error (48%). The remaining results are shown in Fig. 4B.
Fig. 4
Summary of patient insulin injection technique errors. A Proportion of patients making a given number of errors. B Proportion of patients making a specific insulin injection error
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A notable improvement in the number of errors during the assessment and follow-up visits was observed during the study. Specifically, patients made an average of 3.16 errors during the initial visit, but this number significantly decreased to 2.12 errors at the follow-up timepoint (p value < 0.01). This demonstrates a statistically significant mean reduction of 1.04 errors.
Changes in Injection Technique
At follow-up, we observed a decrease in the number of errors regarding injection force, need to push harder for larger insulin doses, attention to force, LH assessment frequency, time needle is held in the skin, pen needle reuse, injection angle, skin lift, and size of the injection area. The remaining tests—pen needle length, the frequency of rotation of the injection site, taught injection site rotation as well as maximum dose at one time—showed no significant changes. No increase in the number of errors was observed in any of the domains. A summary of the results can be found in Figs. 5 and 6 and the odds ratios, confidence intervals, and adjusted p values can be found in Fig. S4.
Fig. 5
Comparison of the number of errors. The plot compares the number of errors made by patients at the initial assessment visit versus the follow-up visit. Comparison was made using a paired t test
Fig. 6
Changes in injection technique (assessment vs. follow-up). Results from the pre–post mid-p McNemar tests are shown as mosaic plots. The width of the segments represents the proportion of the total sample for the follow-up results, and the height of the segments represents the proportion of the total sample for the assessment results. The size of the segments is proportional to the sample size for each of the four possible combinations: correct–correct, correct–incorrect, incorrect–correct, and incorrect–incorrect
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×
Injection Force
The proportion of participants who answered correctly according to the FIT recommendations during the initial assessment and incorrectly during the follow-up visit (6.80%; n = 10) was significantly lower (padj = 0.02) than the proportion who answered incorrectly during the initial assessment and correctly during the follow-up visit (18.4%; n = 27). The remaining 74% of the participants did not change their behaviour, with 44.9% choosing a correct answer during both assessments, and 29.9% choosing an incorrect answer during both assessments. The effect size was judged to be medium (Cohen’s g = 0.23).
“Need” to Push Harder for Larger Insulin Doses
Most of the participants chose the same of response on both visits, with 74.8% (n = 110) choosing according to FIT recommendations at both visits, and 5.44% (n = 8) choosing a suboptimal option. Of the remaining patients, 14.3% (n = 21) changed their response from a suboptimal to an optimal option, with only 5.44% (n = 8) selecting the correct answer during the initial assessment and changing it to an incorrect answer during the follow-up visit. This result was considered statistically significant (padj = 0.04) with a medium effect size (Cohen’s g = 0.22).
Attention to Injection Force
Of the 147 participants, 59 (40.1%) changed their opinion from the assessment to the follow-up visit, with 39 (26.5%) switching from an incorrect response to one in line with FIT recommendations, and 20 (13.6%) switching their response from the ideal to a suboptimal response. While this result is statistically significant (padj = 0.031) with a medium effect size of 0.16, 51 patients did not change their opinion and answered they did not pay attention to how hard they pushed the needle.
Time the Needle is Held in the Skin
Most participants stated they held the needle in the skin for 10 s or more regardless of the assessment session (67.3%; n = 99). Most of the remaining patients (27.9%; n = 41) switched from an incorrect response to responses consistent with the FIT recommendations, with only one switching from a correct practice to an incorrect one, and six deciding to remain with their incorrect insulin application practice. This result was statistically significant (padj < 0.01) and had a large effect size (0.48) according to Cohen’s g statistic.
Pen Needle Reuse
Descriptive statistics revealed that most patients reported using a new needle for each insulin injection, with 83% indicating they never reused a needle (Fig. S2, panel G); 15.6% (n = 23) of the patients switched from reusing needles to never reusing them, while 5.44% (n = 8) changed their behaviour and began reusing needles after previously reporting never doing so. Results indicated that more patients improved their needle reuse behaviour during the follow-up assessment (padj = 0.026), with a medium effect size (Cohen’s g = 0.24). Overall, the findings suggest that patients demonstrated an overall positive trend in their needle reuse behaviour.
Injection Angle
As with the LH assessment frequency, most patients (83.7%; n = 123) injected insulin at the recommended 90° angle when asked on both the assessment and follow-up questionnaires. Of the remaining patients, 12 (8.16%) switched from injecting insulin at a 45° angle to injecting it at a 90° angle, with two of them (1.36%) going in the opposite direction. The remaining 10 patients (6.8%) remained with their original injection technique of injecting at a 45° angle. Overall, the mid-p McNemar test showed statistical significance (padj = 0.031) and a large effect size (Cohen’s g = 0.36).
Size of Area of Injection
When examining the size of the area the injection, a total of 116 (78.9%) patients continued with their original area size, with 31 (21.12%) changing the area size of the injection at the follow-up visit. Of these 31 patients, 27 (18.4%) answered that they went from injecting in an area smaller than a postcard to an area the size of a postcard, while the remaining 2.72% (n = 4) started injecting insulin in an area smaller than a postcard. The results were shown to be statistically significant (padj < 0.01), with a patient being 6.75 times more likely to switch to an optimal size injection area than vice versa. The effect size was judged to be large, with a Cohen’s g of 0.37.
Frequency of Rotation of Injection Site
Patients were asked about how often they rotated the insulin injection site, ranging from never to doing so for every injection. Results showed that 64.6% (n = 95) were rotating the injection site every time they injected insulin—both at the assessment and follow-up questionnaires. Among the responses, 19% (n = 28) of patients used to rotate the injection site less than once per injection but changed to rotating every time they injected insulin, while 9.52% (n = 14) went from rotating after every injection to rotating the injection site less often. Ten patients (6.8%) continued to rotate the injection site in a way that may be considered suboptimal. Statistically, the results were judged to be nonsignificant (padj = 0.056).
Pen Needle Length
When asked about the length of pen needle used, most patients answered they used a needle with a length of 4 mm (76% at the assessment, and 77% at the follow-up visit) (Fig. S2, panel J). In total, only 24 out of 147 patients changed the size of the needle after the assessment visit, with 8.16% (n = 12) changing from a needle longer than 4 mm to a needle with a length of 4 mm, and an additional 6.8% (n = 10) changed from a 4-mm needle to a longer one. Statistically, the results were judged to be nonsignificant (padj = 0.624). According to the FIT recommendations, using a 4-mm needle is considered optimal across a wide range of body mass indexes (BMIs) to avoid the risk of intramuscular injections while providing an equivalent HbA1c control to larger pen needles [19, 20].
Skin Lift
In most cases, skin lift does not need to be performed when using 4- or 5-mm needles [17, 21], which were the sizes used by 88% and 100% of the patients at the assessment and follow-up visits, respectively. From the remaining 12% at the assessment visit, only 1% were using a 6-mm needle and 11% were unsure of the needle size they were using. When a 6-mm needle is used, a skin lift may or may not be warranted depending on a case-by-case basis [17]. A modest change was observed, with 13% fewer patients performing a skin lift at the follow-up appointment (Fig. S2, panel I).
Discussion
Physician Perspectives on Injection Technique Education
Regarding physician practices, it is encouraging to note that a large proportion of physicians (44%) reported providing the initial training for insulin injection themselves. This indicates a hands-on approach by physicians in ensuring that patients receive proper education on injection technique. However, it is concerning that 12% of physicians reported never observing how patients deliver their insulin. Similarly, while 37% of physicians reported examining the injection site at least once per year, 38% mentioned doing so only when clinically appropriate. These findings suggest a need for increased education and monitoring among physicians regarding patients’ injection technique and injection sites to ensure optimal outcomes.
Familiarity with the FIT recommendations, which provide evidence-based guidance for injection technique, was another area explored in the study. Unfortunately, 50% of physicians reported not knowing about these recommendations, indicating a significant gap in knowledge among healthcare providers as well as an area of opportunity for educational initiatives. Additionally, while 19% reported being familiar with the recommendations but not using them, only 19% reported being familiar with and using the recommendations with their patients who inject insulin. This discrepancy between knowledge and practice highlights the need for further education and dissemination of the FIT recommendations among physicians.
Confidence in discussing a patient’s technique for site rotation is crucial for effective patient education. The results indicate that only 31% of physicians reported being completely confident in discussing site rotation, with 56% reporting being fairly confident. This suggests a potential area for improvement in physician education and training to enhance their confidence and competence in addressing this important aspect of insulin injection.
These findings imply that an important proportion of physicians might lack the essential knowledge and confidence needed to effectively treat patients with diabetes who require insulin therapy. This knowledge gap could potentially result in suboptimal patient care, leading to complications and poor health outcomes. For instance, improper insulin injection techniques can cause pain, discomfort, and even serious health issues for patients [3‐5].
Addressing this issue requires a multifaceted approach. First and foremost, medical schools and residency programs should integrate comprehensive diabetes care training, including the latest recommendations like FIT, into their curricula. Continuous medical education should also be encouraged to keep practising physicians updated with the latest guidelines and best practices. Healthcare institutions should establish regular assessments to monitor physicians’ adherence to these guidelines in their clinical practice.
Additionally, fostering collaboration between healthcare providers, such as endocrinologists, diabetes educators, and primary care physicians, can enhance knowledge sharing and improve the overall quality of care provided to patients with diabetes. Ultimately, closing the knowledge gap among physicians in insulin therapy is vital for ensuring that patients receive the best possible care and have the best chances of managing their condition effectively.
Identifying barriers to patient education is essential for developing strategies to overcome them. Physicians who do not have a certified diabetes educator identified lack of time, personnel and support, and lack of effective educational material as the top three barriers in this study. These findings emphasize the importance of addressing resource constraints and providing physicians with adequate support and educational materials to facilitate patient education on injection technique.
The study examined changes in physician behaviours related to LH assessment frequency and teaching injection site rotation. Results showed that some physicians made adjustments during the follow-up visit. In terms of LH assessments, there was a positive trend with some physicians reducing the frequency while others increased it to align with recommendations. However, further improvement is necessary to ensure optimal LH assessment practices. Regarding teaching injection site rotation, most physicians reported instructing patients about appropriate rotation during both the assessment and follow-up visits.
A survey conducted between 2014 and 2015 in 42 countries found that the most common complication of injecting insulin is LH which was correlated with higher insulin consumption and an increase in complications. Injection errors correlated with LH were incorrect rotation of injection sites, use of smaller injection zones, and reuse of pen needles. As well, routine inspection of injection zones by healthcare professionals (HCPs) correlated with lower rates of LH [22]. Our survey results highlight that these factors, including infrequent LH assessment, incorrect rotation of injection sites, use of smaller injection zones, and reuse of pen needles, were indeed identified as prevalent injection errors. This underscores the pressing need for comprehensive education for HCPs and patients to enhance injection techniques, ultimately reducing LH rates and, consequently, lowering the risk of other associated complications.
Lipohypertrophy is a common concern among individuals with diabetes using insulin therapy, with its prevalence rates displaying considerable variability. Various detection methods have been employed, with superficial subcutaneous ultrasonography (SSU) emerging as the gold standard for identifying non-palpable LH, while palpation is another common diagnostic tool [23]. Factors such as total cholesterol levels, short-acting insulin doses, and the presence of coronary artery disease have been correlated with LH [23]. However, epidemiological data reveals substantial differences in LH prevalence, ranging from 11.1% to 73.4% in recent years [24]. This variability may stem from differences in detection capabilities among healthcare providers and the intricate morphological characteristics of LH [24]. Patient education and awareness appear pivotal, with studies identifying factors like the lack of injection site rotation and low education levels as contributing to LH development [25]. Ultrasound detection consistently reveals a higher LH prevalence compared to clinical examination, reaching 90% in some instances [26]. Clinically detected LH is linked to increased insulin usage and higher HbA1c levels, underlining its clinical significance [26]. Nevertheless, physical examination often results in false negatives, further emphasizing the need for consistent, effective detection methods [24]. Physician awareness plays a pivotal role in LH identification, with a survey in China revealing varying levels of awareness among healthcare providers, highlighting the need for standardized detection approaches and increased education within the medical community [27]. In summary, LH prevalence rates fluctuate widely, necessitating improved detection methods and emphasizing the critical roles of patient education and healthcare provider expertise in mitigating LH’s impact on diabetes management.
In summary, there is a need for increased vigilance in monitoring patients’ injection technique and injection sites, addressing gaps in physician knowledge of FIT recommendations, and overcoming barriers to patient education on injection technique.
Needle-Specific Considerations
The study investigated needle length preferences and needle reuse behaviours of patients using insulin pens. Most patients consistently used a 4-mm needle, aligning with recommended practice [17]. However, it is important to note that in some cases needle size is determined by the prescribing physician, so this might not always be a patient-modifiable factor.
In terms of the skin lift technique, most patients were using 4- or 5-mm needles, which do not require a skin lift for the majority of the patients according to FIT recommendations [17, 21]. This demonstrates a good level of awareness among patients regarding the appropriate technique for needle insertion. There was a slight decrease in the percentage of patients performing a skin lift at the follow-up visit, suggesting a potential improvement in adherence to the recommended technique.
The majority of patients followed the recommended injection technique at a 90° angle during both assessments. It is worth mentioning that injecting at a 45° angle with a 6-mm needle may be necessary in extremely lean adults if no skin lift is used [17].
Most patients also reported using a new needle for each injection, indicating adherence to safe practices, similar to the results obtained by Bari et al. in 2020 [2]. This aligns with the recommendations emphasizing the use of new needles to maintain injection safety and reduce the risk of complications. Furthermore, a significant proportion of patients showed an improvement in their needle reuse behaviour during the follow-up assessment, transitioning from reusing needles to never reusing them. This suggests that basic feedback at point of care may have had a positive impact on patient behaviour.
Findings suggest positive trends in needle length preferences and needle reuse behaviours, but further investigation is needed. For instance, objective measures like pharmacy refill data could provide a more accurate assessment of needle reuse. Overall, the study highlights the importance of education and support to enhance safe injection practices.
Common Insulin Injection Technique Errors Among Patients with Diabetes: Implications for Education and Care
The results of our study align with previous research that identified common insulin injection technique errors among patients with diabetes. Specifically, we found that patients are principally making errors in choosing an area that is too small for injection, not paying attention to injection force, and the injection force applied when injecting insulin. These findings are consistent with previous studies that identified similar technique errors in Canada [2, 6]. Of note, none of the evaluated domains changed to a suboptimal response with only the frequency of rotation sites showing no improvement. Importantly, this study also showed that feedback and education at the point of care for patients and clinicians may help improve injection technique, albeit in a minor way. This suggests that incorporating education into routine care could be an effective way to improve insulin injection technique practices among patients with diabetes in Canada and potentially support improved patient outcomes.
Several peer-reviewed studies underscore the pivotal role of patient education in optimizing injection technique and, consequently, improving diabetes management outcomes. Chen et al. found that Chinese patients, when educated on proper injection techniques such as avoiding LH sites and using 4-mm, 32-G needles, achieved a safe reduction in total daily insulin dose while maintaining glycaemic control [28]. Similarly, the LH Monitoring Study (LIMO) in Belgium reported decreased LH, improved rotation practices, and reduced needle reuse after providing patients with 4-mm pen needles and online injection technique education [29]. The UK LH Interventional Study, led by Smith et al., documented substantial reductions in LH, fewer injections into LH sites, and lowered total daily insulin doses following intensive education and needle switch [30]. Collectively, these studies underscore the critical importance of educating patients in proper injection techniques to enhance diabetes management outcomes, including glycaemic control and insulin dose reduction. However, it is essential to acknowledge that the effectiveness of such education can be hindered by the existing disparities in healthcare training across regions and demographics. To ensure consistent and equitable results in diabetes management, there is an urgent need for a more homogeneous approach to the training of health professionals in the field, thereby guaranteeing that all patients, regardless of their background, receive the same high-quality education and care.
Our results indicate that progress has been made and that the educational intervention of the KT prompts may have impacted this positive observation. However, more than three errors on average are still being made by these patients, indicating that additional strategies to optimize injection technique are warranted. It is important to also consider that these changes were observed during a single follow-up visit which may not fully capture actual changes over time; thus, there is an opportunity for future studies to capture ongoing and long-term behavioural changes.
Implications and Recommendations
The results of our study have several implications for diabetes care in Canada. First our findings suggest there is a need for ongoing education and support for patients to improve their insulin injection technique, especially for those clinics that do not have access to a certified diabetes educator. In Canada, it has been previously demonstrated that integrating diabetes education teams in primary care can significantly improve clinical outcomes and diabetes management [14, 31]. Second, regular assessment of insulin injection technique should be incorporated into routine care to identify errors and provide feedback and education to patients. On the basis of our findings, we suggest that further research is required to identify additional ways to improve insulin injection technique practices among patients with diabetes.
As well, with telemedicine becoming more widespread, intensive and adequate training is highly warranted so that health professionals can adequately assess and monitor the patient’s understanding and adherence to correct injection practices during virtual visits. As well, incorporating tailored training modules that integrate multimedia resources and interactive simulations, alongside video-based assessments enabling patients to share their injection procedures for remote evaluation and real-time guidance would potentially improve virtual patient care.
Lastly, it is important to note that the results obtained during the study were based on a single pre–post interventional design; continued training could provide improved results for both physicians and patients alike.
Potential Interventions and Resources
One potential solution for providing ongoing education and support to patients, especially those in remote or underserved areas, is the use of digital health technology and mobile resources [32]. This is important because continuous and long-term education has been proven to be more effective in improving patients’ technique and outcomes than single sessions of training [33]. However, our findings reveal that only about 40% of physicians conduct less than 20% of their visits virtually. This presents an opportunity to improve the frequency and accessibility of patient education. Notably, 38% of physicians reported they struggle to educate their patients on injection techniques as a result of a lack of time; telemedicine may serve as a remedy for this issue. Additional research that evaluates the implications and challenges of providing education and assessing patient’s injection technique through telemedicine would provide valuable insights for the development of programs that help to bridge existing gaps. Performance monitoring integrated into future educational interventions would significantly improve the evaluation of educational effectiveness.
Study Limitations
This study was not designed to capture clinical patient outcomes. Additionally, comorbidities or other potential confounders (e.g. socioeconomic status, education level, language barriers) were not obtained by the patient survey and thus adjustment for their impact on the number of errors or changes in behaviours was not performed. As a result of the nature of the study, the sample is heterogeneous in terms of types of diabetes, and future studies that identify common errors and the impact of education on patients living with one specific type of diabetes would be of great value to design programs tailored to each patient’s specific needs.
Conclusion
This study highlights that there is still work to be done to optimize injection technique for patients with diabetes. Incorporating education into routine care and regular assessment of technique could be tools to improve patients’ insulin injection practices [9‐12]. Leveraging digital health technology can provide additional support and education to patients [32], especially in remote or underserved areas where a certified diabetes educator is not available. Addressing common technique errors can reduce the risks associated with incorrect insulin injection technique and ultimately improve diabetes control and outcomes for patients. Further research is needed to evaluate the effectiveness of these interventions and identify additional ways to enhance insulin injection technique practices among patients with diabetes, as well as differences in injection technique outcomes based on different levels of experience and education of physicians.
Acknowledgements
We would like to express our sincerest gratitude to the participants of this study. We appreciate their cooperation and trust, which made this study possible. As well, we would like to acknowledge Sergio Romero, MSc for supporting the data analysis in this study.
Medical Writing/Editorial Assistance
We thank the team at CTC Communications for their editorial assistance in the development of this article.
Declarations
Conflict of Interest
Basel Bari reports being a member of an advisory board or equivalent with Novo Nordisk, AstraZeneca, Boehringer Ingelheim, Sanofi, and Eli Lilly. Basel Bari also declares membership of a speakers’ bureau with Merck, Novo Nordisk, Sanofi, Boehringer Ingelheim, AstraZeneca, and Eli Lilly. Basel Bari has received or will be receiving a grant or an honorarium from CCRN, Sanofi, Boehringer Ingelheim, and Becton, Dickinson and Company (Embecta). Marie-Andrée Corbeil reports being a member of an advisory board as a speaker for Novo Nordisk, Eli Lilly, Sanofi, Abbott, Ascensia, Boehringer Ingelheim, Merck, AstraZeneca, Dexcom, and has taken part in an advisory board for Dexcom, Abbott, Novo Nordisk, AstraZeneca, and Amgen. She has or will be receiving an honorarium from Becton, Dickinson and Company (Embecta). Gail MacNeill is the chair of the FIT board of Canada which is sponsored by Embecta. Scarlett Puebla-Barragan reports that the company she works for, CTC Communications, has received funding from Embecta Canada. Arthur Vasquez reports acting as consultant for Novo Nordisk, Janssen Pharmaceuticals, AstraZeneca, Eli Lilly, and Becton, Dickinson and Company (Embecta). Arthur Vasquez also received an unrestricted grant from Janssen Pharmaceuticals and has been a paid speaker for Janssen Pharmaceuticals and AstraZeneca.
Ethical Approval
The protocol for the Injection Technique Practice Reflective 2.0 study (Pro00062488) was reviewed and approved by the Advarra® institutional review board on May 5, 2022, and adhered to the principles of the Declaration of Helsinki of 1964 and its later amendments, Good Clinical Practice guidelines, and relevant laws and regulations. Advarra®, established in 1983, offers institutional review board (IRB), institutional biosafety committee (IBC), and research quality and compliance consulting services in North America. Prior to participating in the study, written informed consent was obtained from both patients and physicians.
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