Risking Health to Avoid Injections

Improved glycemic control reduces the risk of long-term diabetes complications (1–3). However, subcutaneous insulin injections represent a barrier to achieving “optimal” blood glucose levels, particularly among type 2 diabetic patients (4). Indeed, some patients even delay initiation of therapy to avoid injections (5). This study used conjoint analysis to quantify the relative importance that Canadian patients with type 2 diabetes place on short-term treatment outcomes and on the frequency of insulin injections. A total of 1,886 patients enrolled in a Canadian consumer panel ( n = 70,000) were mailed a questionnaire. Study entry criteria were age ≥18 years and self-reported type 2 diabetes. The choice format conjoint questionnaire was designed to reveal the relative importance patients place on various health outcomes and treatment attributes associated with insulin therapy. This format offers advantages over other methods of quantifying health care preferences (6–11). The questions comprised 12 hypothetical treatment choices, including varying numbers of daily insulin injections using an insulin pen (one to three injections), levels of glucose control (optimal, suboptimal, and poor as fasting plasma glucose levels of 4–7, 7.1–10, and >10 mmol/l, respectively), HbA1c (A1C) levels 8.4%), and numbers of mild-to-moderate hypoglycemic events per month ( 2). Insulin pens were chosen over other methods of subcutaneous insulin delivery because they are the predominant method used in Canada (12). One alternative in each question was a constant reference condition. …