Comparison of the quality of life in people with type 1 diabetes treated by continuous subcutaneous insulin infusion vs multiple daily injections

Diabetes Education

Our clinic has developped several "on going" Diabetes Education Programs, adapted to each type of diabetes and treatment mode. Diabetes education is mainly provided on individual basis including the patient´s family but there are also periodic group classes for those who wish to attend.
The type’s 1 program is known as "Intensive Diabetes Education" (IDE) and is given on six one-hour education sessions in consecutive days, in order to cover all the necessary topics for a flexible insulin therapy, the initial education intervention are followed by an annual Education Review Course (EDC).
Our Pump Education Program (PEP) is an outpatient eight one-hour session program perfomed during a three week period and has been published. All the pump candidates have attended first the IDE program.

Since it is well known that technical diabetes knowledge does not necessarily result in good metabolic control during the initial patient education assessment we stress the importance of attitudes and behaviour and by asking a lot of questions and careful listening and analizing patient’s anwers we try to help them to identify their particular reasons and barriers

There were 32 patients (17 females and 15 males) with type 1 diabetes of more than 2 years duration, who either treated their diabetes by CSII or MDI. After having been informed of the purpose of the study they agreed to answer the questionnaire during a routine follow-up visit at the out-patient diabetes clinic in Gijon between July and October 2000.

Patients were elegible according to previously established criteria: duration of type 1 diabetes greater than 2 years, absence of severe visual or renal complications, and no evidence of mental disorder. All patients had been treated for at least 6 month with their respective therapy. The patients were matched pairwise for age and duration of diabetes. The clinical characteristics of the patients are summarized in table 1.

Table 1: Clinical Characteristics of Patients
Group n HbA1c Diabetes duration Age
MDI 16 7.03 ± 1.22 12,60 ± 6.20 31.94 ± 17.80
CSII 16 6.18 ± 0,63 13.00 ± 8.10 31.38 ± 17.08

There were no significant differences between the patients with respect to the matching variables of age and duration of diabetes; but the differences in HbA1c were significant (p<.05). Table 2 shows the scores of both groups in the quality of life scales.

Table 2: Quality of Life Scores in groups
Scale CSII MDI Total Reviriego et al. (1) P (CSII vs. MDI)
Satisfaction 26.81 35.88 31.34 31.28 .0045**
Impact 40.25 44.44 42.34 39.37 .1208
Worry-Soc 13.19 16.56 14.88 14.44 .2052
Worry-Diab 8.38 10.25 9.31 9.78 .1080

(1) Data from Reviriego et al.’s Spanish reliability study (1996), N=105 patients with IDDM

All DQOL scales show more quality of life/less burden and impact with pump treated patients, although only the satisfaction scores are significantly better. Older patients (> 25 years) generally reported a worse quality of life (non-significant). To find out whether there was a different effect of both kinds of therapy on patients who were younger (< 25 years) vs. older (> 25 years) the eight young pairs were compared to the eight pairs with a later onset. Table 3 shows the results.

Table 3: Effects on DQOL on younger vs. older patients
< 25 ys > 25 ys p < 25 ys > 25 ys p
Satisfaction 23.37 30.25 .035 34.37 37.37 .635
Impact 37.75 42.75 .228 42.50 46.37 .268
Worry-Soc 12.25 14.12 .458 16.00 17.12 .832
Worry-Diab 7.1 9.62 .058 11.00 9.50 .556

There are generally higher gains in quality of life in the younger group of pump treated patients. Worry diabetes scores are lower in the younger pump treated patients but are higher in the younger MDI treated patients.

The average scores compare well with data from Reviriego et al. (1996). The impact scores are higher which might be explained by the way education is presented to the patients in the study site. They are informed about all risks to make informed choices which passes the responsibility to them and might raise the significance and impact of the therapy.

Patients with pumps generally score better in the DQOL scales: they feel more satisfaction (significantly), less impact and less worries. This might result from feeling more flexibility, responsibility, and competency to self treats their diabetes. But the lower HbA1c values, which have often been found correlated with quality of life, cannot be ruled out as another explanation of this difference.

It is especially the pump treated young patients who score significantly better in satisfaction than the older group. They also worry less about their diabetes while the MDI treated young people even worry more than the older group. Young people with pumps are often more enthusiastic with their therapy which might explain their higher satisfaction and lower worry. There might also be a site-specific effect because of a special dedication to pump treatment in young people. Their feeling that they practice the most advanced therapy of their diabetes and being shown to do in a competent and self responsible way might increase the QOL of young people in a special way. This effect might be missing in the group of MDI treated young people who might feel to be not as advanced as their pump treated fellows raising more diabetes related anxieties.

But because of the size of the group these speculations should not be taken too far. Since quality of life is a subjective interpretation of reality it is probable that attitudes and expections of the patients towards diabetes, which are shaped by education, become a part of this interpretation. The data show that especially young people experience a benefit for their QOL by pump treatment. Since young people generally have more difficulties in self-caring for their diabetes pump treatment might be a way to inspire them for an active and self responsible diabetes therapy.

Reviriego J, Dolores Millan M, Millan M. (1996). Evaluation of the diabetes quality-of-life questionnaire in a Spanish population. PharmacoEconomics 10, 614 - 622
R.M. Antuña de Alaiz (1999). Initiating Outpatient Insulin Pump Therapy: Highlights of an Outpatient Education Program Developed in Spain. Diabetes Spectrum 12:186-188
Ramiro Antuña, Axel Hirsch
Clínica Diabetológica Gijón; Bethanien Hospital Hamburg
education > teaching the educator