Is Your Patient Ready, Willing, and Able?
Many patients are naturals for pump therapy, but it is not for everyone. Some patients need to overcome specific obstacles before the pump will be an asset to their healthcare. Others just do not have the interest or abilities to master pump therapy. Discovering the character and source of motivation through careful screening of the patient is the key to ensuring success in pump therapy.
You must evaluate the physical and psychological readiness of each pump candidate to take on the responsibilities and challenges of pump therapy. The person with diabetes and his or her family need to buy into pump therapy. Input from the patient’s family and other members of the healthcare team will help you discern the patient’s clinical and lifestyle indications for insulin pump therapy (Table 1).
TABLE 1. Indications for Pump Therapy
Clinical Indications
High glucose variability
Elevated A1C
Nocturnal hypoglycemia
Hypoglycemia unawareness
Recurrent hyperglycemia
Preconception
Pregnancy
Extreme insulin sensitivity
Gastroparesis
Early neuropathy or nephropathy, when improvement in glucose control can reduce acceleration of complications
Renal transplantation
Lifestyle Indications
Erratic schedule
Varied work shifts
Frequent travel (probably accompanied by frequent dining out)
Desire for flexibility
A Good Prospect: Ready, Willing, and Able
• Is motivated. Pump therapy requires readiness, preparedness, and a time investment for weeks or months in advance and during the initiation of pump therapy.
• Has realistic expectations. The patient who expresses interest and desire for pump therapy must understand that the pump will not “fix” blood glucose variations automatically, nor will pump therapy grant freedom from frequent SMBG. Pump therapy does not guarantee “good control,” but it can help achieve and maintain improved glucose control with effort from the pump wearer. Children who use the pump must have parents and caretakers with a thorough understanding of what pump therapy involves and the willingness to spend the time needed working with the child and healthcare professionals.
• Demonstrates independent diabetes management. Ideally, MDI therapy precedes pump therapy. MDI as a “stepping stone” to pump therapy often reveals the patient’s suitability. At the very minimum, the prospective pump user should have knowledge of the basics of diabetes education. A thorough knowledge of diabetes and its management and the ability to demonstrate appropriate self-care behaviors (including trouble-shooting and problem-solving skills) provide the foundation for the advanced self-management skills required by pump users. This is one of the reasons pump therapy may not be recommended for newly diagnosed patients (Shalitin 2012).
• Is willing to learn. The person must be able and willing to learn, practice, and demonstrate an understanding of carbohydrate counting, insulin action, and premeal bolus dose calculations using their insulin-to-carbohydrate ratio(s) and correction factor(s), and be able to make insulin dose adjustments in response to hypoglycemia, hyperglycemia, exercise, stress, and illness.
• Has ability to problem-solve. i.e., can use newly acquired skills in managing diabetes.
• Welcomes challenges. The initial few weeks of pump therapy require detailed record keeping of SMBG results, dietary intake, insulin doses, and exercise, as well as frequent (minimum of four daily) blood glucose checks, including “middle of the night” checks (typically at 3:00 a.m.), and frequent (sometimes daily) telephone/email/fax communication with the healthcare professional(s). The pump user must also have patience during the pump initiation period, when appropriate basal rates and insulin-to-carbohydrate ratios are being determined.
• Has the support of family or significant other(s). The decision to initiate pump therapy is a lifestyle-changing decision. Emotional support is crucial to the success of pump therapy. Family members, friends, coworkers, teachers, and others can be of great assistance to the pump wearer. Education about diabetes in general, along with pump therapy education, can help ease the difficulties and challenges of pump therapy initiation.
• Can afford it. Pumps and pump supplies cost thousands of dollars, so verifying the patient’s ability to afford pump therapy is essential. The pump wearer must have either personal resources or adequate insurance benefits. Insurance coverage can range from 50 to 100% for the pump and/or pump supplies. Ask the potential pump wearer to verify their benefits with their health insurance carrier; some pump manufacturers will provide this service to patients. Some insurance companies require a letter of medical necessity from the healthcare prescriber. Additionally, an insurer may cover only a specific brand of pump but may provide benefits for a nonformulary brand with a letter of medical necessity outlining why a specific pump brand (i.e., the pump’s features) is most appropriate for the patient. Medicare covers a pump for a patient with type 1 or type 2 diabetes who (A) has completed a comprehensive diabetes education program, performs at least 4 daily SMBG checks, uses at least 3 injections per day, and meets one or more other glycemic control-related criteria; OR (B), if a patient has been on a pump prior to enrollment in Medicare and has documented frequent (minimum of 4 daily) SMBG checks during the month preceding enrollment and meets one or more other glycemic control-related criteria. Additionally, a prospective or current pump patient must have a documented fasting C-peptide level ≤110% of the lower limit of normal of a lab’s range (e.g., up to and including 0.99 ng/ml, if the low range is 0.9 ng/ml) or be beta-cell autoantibody positive for Medicare insulin pump coverage. The positive autoantibody test allows patients with latent autoimmune diabetes in adulthood (LADA), referred to as type 1.5 diabetes, to qualify for a pump. Always confirm current Medicare coverage. The pump must be ordered by and follow-up care must be managed by a physician who manages multiple pump patients and who works closely with a team, including CDEs, RDs, and nurses who are knowledgeable in use of pump therapy (DHHS 2013).
• Is capable intellectually, physically, and technically. A patient contemplating pump therapy must be able to demonstrate an understanding of the therapy. Intellectually, the patient must demonstrate understanding of insulin-to-carbohydrate ratios and correction (sensitivity) factors and the applications of these parameters to determine appropriate insulin bolus doses. The ability to insert the pump battery(ies), fill and/or place the insulin cartridge/reservoir into the pump, insert the infusion set, wear the pump, and perform the technical functions of the pump is essential.
« Patients with moderate to severe hand arthritis or neuropathy may not be able to press the pump’s buttons or remote device or handle the insulin cartridge/reservoir and infusion sets.
« Patients who are blind or visually impaired may be limited in their choice of pump because of a lack of audio functions or small screen displays.
« Patients who are deaf or hearing impaired may be at greater risk for interruptions in insulin delivery because they have difficulty hearing the pump’s alarm. Pumps with vibrating
