Barriers and Facilitators to the Implementation of a Mobile Insulin Titration Intervention for Patients With Uncontrolled Diabetes: A Qualitative Analysis

Abstract

Background In 2016, a short message service text messaging intervention to titrate insulin in patients with uncontrolled type 2 diabetes was implemented at two health care facilities in New York City. Objective This study aimed to conduct a qualitative evaluation assessing barriers to and the facilitators of the implementation of the Mobile Insulin Titration Intervention (MITI) program into usual care. Methods We conducted in-depth interviews with 36 patients enrolled in the MITI program and the staff involved in MITI (n=19) in the two health care systems. Interviews were transcribed and iteratively coded by two study investigators, both inductively and deductively using a codebook guided by the Consolidated Framework for Implementation Research. Results Multiple facilitator themes emerged: (1) MITI had strong relative advantages to in-person titration, including its convenience and time-saving design, (2) the free cost of MITI was important to the patients, (3) MITI was easy to use and the patients were confident in their ability to use it, (4) MITI was compatible with the patients’ home routines and clinic workflow, (5) the patients and staff perceived MITI to have value beyond insulin titration by reminding and motivating the patients to engage in healthy behaviors and providing a source of patient support, and (6) implementation in clinics was made easy by having a strong implementation climate, communication networks to spread information about MITI, and a strong program champion. The barriers identified included the following: (1) language limitations, (2) initial nurse concerns about the scope of practice changes required to deliver MITI, (3) initial provider knowledge gaps about the program, and (4) provider perceptions that MITI might not be appropriate for some patients (eg, older or not tech-savvy). There was also a theme that emerged during the patient and staff interviews of an unmet need for long-term additional diabetes management support among this population, specifically diet, nutrition, and exercise support. Conclusions The patients and staff were overwhelmingly supportive of MITI and believed that it had many benefits and that it was compatible with the clinic workflow and patients’ lives. Initial implementation efforts should address staff training and nurse concerns. Future research should explore options for integrating additional diabetes support for patients.

Barriers and challenges of using health information technology in home care: A systematic review

“…As shown in Table 2, Facilities category ( n = 35) was the most highly cited category in all the eligible studies, 32–66 then Legislation or regulations ( n = 19), 32,37,39,44,46,48–51,53,56,57,59,67–72 Knowledge and skills ( n = 18) 32,37,39,44,45,48,50,53,55–57,59,66,69,72–76 and Attitudes regarding programme acceptability, appropriateness and credibility ( n = 16) 32,33,35,37,44,45,48,49,52,55,56,69,72,73,75,76 categories. Accessibility of care ( n = 1) and Short‐term thinking ( n = 1) had the least number of barriers and challenges.…”

“…A total of 18 eligible studies 32,37,39,44,45,48,50,53,55–57,59,66,69,73–76 highlighted the barriers and challenges regarding the Knowledge and skills category. One common reported barrier was the lack of end‐user awareness which was identified in 9 studies 39,44,48,53,56,59,72,73,76 .…”

“…Nine studies highlighted the barriers and challenges related to Motivation to change when using IT in home care 33,36,37,43,50,51,56,59,75 . The most frequently cited issue was feeling anxious when using the technology ( n = 2) 51,59 .…”

“…Another major barrier in using technology in home health care was cost, which was mentioned in 14% of studies. Despite many studies that have reported cost as one of the barriers to using technology, 75,95 a study reported that financial issues can be counted as a facilitating factor through allocating a dedicated budget line to the Ministry of Health budget 96 . Problems that need to be addressed are the creation of a model for physicians and nurses to pay for and the lack of sufficient funding to use technology.…”

Efficacy and Safety of a Decision Support Intervention for Basal Insulin Self-Titration Assisted by the Nurse in Outpatients with T2DM: A Randomized Controlled Trial

“… 27 Incorporation of the services of nurse consultant experts is the key for successful patient treatment with BI, both during hospital stay and after discharge. 28 In the Italian Titration Approach Study (ITAS) with insulin Gla-300 in insulin-naïve T2DM, when they wanted to compared the glucose control managed by the patient versus the physician, “nurse assisted” was needed in the patient management group. 17 Involvement of nurses as educators seems very useful in BI treatment.…”