Original Article

Yonago Acta medica 2015;58:101–107

Opinions and Satisfaction Regarding Continuous Subcutaneous Insulin Infusion
Therapy in Adult Patients with Type 1 Diabetes
Ikuko Nishio,* Masami Chujo,* Tsuyoshi Ohkura† and Hideyuki Kataoka**Department of Adult and Elderly Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japanand †Division of Molecular Medicine and Therapeutics, Department of Multidisciplinary Internal Medicine, School of Medicine, Tottori
University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACT
Background This study examined the treatment satisfaction of type 1 diabetic patients undergoing continuous subcutaneous insulin infusion (CSII) therapy, andpatients’ thoughts regarding CSII.
Methods We provided a self-administered questionnaire survey over the internet. Participants were 106
individuals with type-one diabetes aged 20 years orolder, undergoing CSII. The survey examined patients’treatment satisfaction, and their thoughts regarding CSII.
Descriptive statistics were calculated. We compared
relationships between treatment satisfaction and othervariables using the Kruskal-Wallis rank sum test, andperformed content analysis on participants’ thoughts regarding CSII.
Results Regarding treatment satisfaction, the response, “neither of them” was the most frequent. Comparing relationships between treatment satisfaction andother variables, significant differences were found forthe variables “age,” “presence of dissatisfaction regarding doctors’ response,” and “presence of a significant
medical expense burden.” Participants’ thoughts regarding CSII were classified into 10 categories.
Conclusion Participants expressed positive evaluations, such as that their blood sugar control had improved due to CSII, and that they perceived improvement in their health. Participants also expressed negativeevaluations, however, such as that medical expenses
resulting from CSII were high, and that these expenses
may cause distress and future economic insecurity. In
future, patients may benefit from nursing support that allows patients to confidently continue with CSII.

Type 1 diabetes is a disease in which pancreatic betacells are destroyed, causing low insulin secretion that
leads to a state of absolute insulin deficiency. Approximately 8,000 people currently suffer from type 1 diabetes in Japan as reported by the Ministry of Health, Labour and Welfare. It often develops during childhood oradolescence. Patients require lifetime insulin treatment
to survive.
Blood sugar control in types 1 and 2 diabetes patients is influenced by meal content, volume, and timing,
as well as degree of physical activity and physical condition. Patients must therefore adjust their insulin dosage and the timing of insulin injections to match thesevariables.1 However, this is a major challenge and many
patients are unable to successfully control their blood
sugar levels. A growing number of patients are therefore
choosing to undergo continuous subcutaneous insulin
infusion (CSII) therapy to make their treatment regimens match their lifestyle more closely. CSII therapy isa method of continuously pumping insulin via a subcutaneous infusion route into the patient’s abdominal wall. A
meta-analysis comparing multiple daily injection (MDI)
therapy with CSII therapy has shown that CSII therapy
produces better blood sugar and HbA1c levels than MDI
therapy does and enables insulin dosages to be reduced.
The usefulness of CSII therapy is also being seen in
insulin-dependent diabetes patients whose insulin secretion capabilities have been significantly impaired and in
pregnant women suffering diabetic complications withwide fluctuations in blood sugar levels.2, 3
Although CSII therapy is widely known in the U.S.
and other countries as one option for diabetic insulin
therapy, it remains little known in Japan and is not widely used. Because of this, very few studies have thus far
been published and the opinions of patients undergoing
CSII therapy and their degree of satisfaction with it are
not yet known.
We therefore decided to conduct a study targetingtype 1 diabetes patients undergoing CSII therapy withthe aim of investigating their opinions on this treatment
and their degree of satisfaction with it. The objective was

Key words

continuous subcutaneous insulin infusion;
treatment satisfaction; type 1 diabetes

Corresponding author: Ikuko Nishio
ikurin@med.tottori-u.ac.jp
Received 2015 May 13
Accepted 2015 June 19
Abbreviations: CSII, continuous subcutaneous insulin infusion;
MDI, multiple daily injection101

I. Nishio et al.

to make the findings of this study useful for providing
nursing assistance to type 1 diabetes patients who are on
CSII therapy.

their consent to participate in the study once they had
answered the questionnaire and returned it to us. Eli
Lilly Japan obtained approval from the responders.

SUBJECTS AND METHODSRESULTS

Participants and data collection

The study participants’ basic attributes

With the cooperation of Eli Lilly Japan (Kobe, Japan),we used type 1 diabetes patients on CSII therapy, aged
over 20, and registered with the Diabetes Net’s email
magazine as the study participants. We asked the individuals to answer a questionnaire survey via the Internet. We displayed the questionnaire sheets and answer
columns on the web and asked the individuals to send
their answers to us. A total of 106 patients were used as
the study participants.
The questionnaire consisted of eleven items altogether, including six items on basic attributes, one on theparticipants’ degree of satisfaction with CSII therapy,
and five on their opinions about diabetes treatment: i)
I have never been dissatisfied with the way the doctor
dealt with me; ii) My current work is not affected by mydiabetes; iii) I am mentally stable; iv) I do not mind if
the treatment is complicated, as long as my diabetes improves and v) Payment for medical treatments imposes aheavy financial burden. It also included an unstructured
section asking the participants’ opinions on CSII therapy. Data were collected from 106 participants between
March and April 2013.

Table 1 shows the study participants’ basic attributes.
Table 1. The study participants’ basic attributes
n (%)

Item
GenderAge groups(years)Occupation
Marital status
Duration of diabetes(years)Monthly amount of the
medical expenses(yen)

Data analysis

Simple compilations were made for “basic attributes,”“degree of satisfaction with CSII therapy,” and “views
on diabetes treatment.” We used the Kruskal-Wallis
rank sum test to compare the relationships between“basic attributes” and “degree of satisfaction with CSII
therapy” and between “views on diabetes treatment”
and “degree of satisfaction with CSII therapy.” Analysis
was completed using SPSS Statistics for Windows (IBM,Armonk, NY) with a significance level of 5%. We used
qualitative software to perform content analysis (as defined by Bernard Berelson) on the participants’ opinions
about CSII therapy (unstructured section).

Male
Female
< 30
30–39
40–49
50–59
60–69
Employed
UnemployedSingleMarried
<5
5–10
11–20
> 20
< 5000
5000–10000
10000–15000
15000–20000> 20000

23 (21.7)
83 (78.3)
14 (13.2)
39 (36.8)
27 (25.5)
19 (17.9)
5 (6.6)51 (48.1)
55 (51.9)
62 (58.5)
44 (41.5)
26 (24.5)
13 (12.3)
29 (27.4)
38 (35.8)
4 (3.8)1 (0.9)10 (9.4)
48 (45.3)
43 (40.6)

Degree of satisfaction with CSII therapy

Concerning “degree of satisfaction with CSII therapy,”
25 participants (23.6%) were “satisfied,” 18 (17.0%) were“dissatisfied,” and 63 (59.4%) were “neither satisfied nor
dissatisfied.” The most frequently-cited answer was “neither satisfied nor dissatisfied.”Views on diabetes treatment

Almost two-thirds (n = 74 or 69.8%) of participants affirmed that they “did not mind if the treatment is complicated, as long as my diabetes improves.” Sixty-three(59.4%) affirmed their “current work is not affectedby my diabetes” and sixty (56.6%) affirmed their own
mental stability. Many patients answered “yes” for thesethree items. On the other hand, a similar percentage (n =61 or 59.4%) indicated they “had been dissatisfied withthe way the doctor dealt with me.” Slightly more thanhalf (n = 57 or 53.8%) denied that payment for medical
treatment was a burden. Many patients answered “no”
to these two items.

Ethical considerations

The participants were told, via the Internet, that information obtained in the course of the study would not be
used for purposes other than research, that the survey
was being completed anonymously so individuals would
not be identified, that their study participation was basedon their own free will, and that they would not suffer
any disadvantages even if they refused to provide answers. The subjects were regarded as having given us
102

Satisfaction with CSII therapy in T1D patients

Comparison of the relationship between the participants’ basic attributes and their degree of satisfaction with CSII therapy

No significant differences were seen by gender, marital
status, occupation, treatment history, or the amount ofmonthly medical payments. Many of those who answered that they were “satisfied” had a long treatment
history (Table 2).

A significant difference in age was seen in comparing
the relationship between the participants’ basic attributes and their degree of satisfaction with CSII therapy.

Table 2. Comparison of the relationship between the participants’ basic attributes and their degree ofsatisfaction with CSII therapy
Items

Satisfied(n = 25)

Dissatisfied(n = 18)

Neither satisfied
nor dissatisfied(n = 63)

Total

Male
Female< 30
30–39
Age groups
40–49(years)
50–59
60–69
Employed
Occupation
UnemployedSingleMarital status
Married<5
Duration of diabetes 5–10
(years)11–20> 20< 5000
5000–10000
Monthly amount of
the medical expenses 10000–15000
15000–20000(yen)> 20000

6 (5.7)19 (17.2)
4 (3.8)11 (10.4)
8 (7.5)2 (1.9)0 (0)13 (12.3)
12 (11.3)
13 (12.3)
12 (11.3)
5 (4.7)4 (3.8)4 (3.8)12 (11.3)
1 (0.9)1 (0.9)3 (2.8)11 (10.4)
9 (8.5)3 (2.8)15 (14.2)
3 (2.8)9 (8.5)4 (3.8)2 (1.9)0 (0)6 (5.7)12 (11.3)
10 (9.4)
8 (7.5)4 (3.8)3 (2.8)8 (7.5)3 (2.8)1 (0.9)0 (0)0 (0)10 (9.4)
7 (6.6)14 (13.2)
49 (46.2)
7 (6.6)19 (17.9)
15 (14.1)
15 (14.1)
7 (6.6)25 (23.6)
38 (35.9)
32 (30.2)
31 (29.3)
17 (16.0)
6 (5.7)17 (16.0)
23 (21.7)
2 (1.9)0 (0)7 (6.6)27 (25.5)
27 (25.5)

23 (217)83 (78.3)
14 (13.2)
39 (36.8)
27 (25.5)
19 (17.2)
7 (7.3)44 (41.5)
62 (58.5)
55 (51.9)
51 (48.1)
26 (24.5)
13 (12.3)
29 (27.4)
38 (35.9)
4 (3.8)1 (0.9)10 (9.49
48 (45.3)
43 (40.6)

GenderP-value
ns
✽
✽
✽
✽
✽
ns
ns

ns

ns

*P < 0.05. CSII, continuous subcutaneous insulin infusion; ns, not significant.

Table 3. Comparison of the relationship between the participants’ degree of satisfaction with CSII treatment andtheir views on diabetes treatment
Satisfied(n = 25)

Items

Dissatisfied(n = 18)

Neither satisfied
nor dissatisfied(n = 63)

Total

1. I have never been dissatisfied with Yes
the way the doctor dealt with meNo

10 (13.5)5 (6.8)16 (21.6)

31 (29.2)

15 (20.3)

13 (17.5)

46 (62.2)

74 (69.8)

2. My current work is not affected by Yes
my diabetesNo

9 (12.2)

9 (12.2)

20 (27.0)

38 (35.8)

16 (21.6)

8 (10.8)

39 (52.7)

63 (59.4)

Yes

14 (18.9)

8 (10.8)

38 (51.4)

60 (56.6)No

1 (1.4)9 (12.2)

24 (32.4)

34 (32.1)

4. I do not mind if the treatment is Yes
complicated, as long as my diabetesNo
improves
Yes
5. Payment for medical treatments
imposes a heavy financial burdenNo

17 (23.0)

15 (20.3)

29 (39.2)

61 (57.5)

8 (10.8)

2 (2.7)33 (44.6)

43 (40.6)

16 (21.6)

10 (13.5)

23 (31.1)

49 (46.2)

9 (12.2)

8 (10.8)40 (54.1)

57 (53.8)

3. I am mentally stable*P < 0.05. CSII, continuous subcutaneous insulin infusion; ns, not significant.

103

P-value
ns
ns
ns
✽
✽

I. Nishio et al.

Comparison of the relationship between the participants’ degree of satisfaction with CSII treatment
and their views on diabetes treatment

DISCUSSION

In comparing the relationship between the participants’views on diabetes treatment and their degree of satisfaction with CSII therapy, we found a significant difference
for the items, “I do not mind if the treatment is complicated, as long as my diabetes improves;” and “payment for medical treatments imposes a heavy financial
burden.” No significant differences were seen in thefollowing items: “I have never been dissatisfied with theway the doctor dealt with me”, “my current work is notaffected by my diabetes;” and “I am mentally stable”(Table 3).

In terms of the degree of satisfaction with CSII therapy,
approximately 20% of the patients answered that they
were satisfied and approximately 10% answered thatthey were dissatisfied. However, the largest number ofpatients—approximately 60%—answered that they wereneither satisfied nor dissatisfied. The more favorable theblood sugar control of type 1 diabetes patients is, thehigher their degree of satisfaction with treatment tends
to be.4 With CSII therapy, moreover, a certain amountof time is needed to set the basal levels and to master thetechnique of handling the insulin pump and peripheral
equipment; it takes time to prepare all of the conditions
necessary for improving blood sugar control. Even ifpatients switch to CSII therapy, not everyone sees theirblood sugar control improve.5 Therefore, many of ourstudy’s targets were assumed to have answered “neither
satisfied nor dissatisfied” since they felt that, even if theyswitched to CSII therapy, their mastery of the techniques
might be insufficient or their blood sugar control might
not improve. On the other hand, insulin is their lifeline
and they cannot revert to worsening health. As a result,they could not select either “satisfied” or “dissatisfied.”
In a comparison of the relationship between the participants’ basic attributes and their degree of satisfaction
with CSII therapy, a significant difference was seen interms of age. Most participants were in their 30s to 40s.
In terms of treatment history, many had been in treatment for 20 or more years, followed by 10–20 years,
so the age of onset is assumed to have been when theparticipants were relatively young. It is reported that,when patients who have undergone MDI therapy formany years switch to CSII therapy, their burden both atwork and in family living is reduced. On the other hand,
however, CSII therapy has its drawbacks. For example,
it leaves catheter needle scars and can cause pain, depending on the angle of the catheter needle.5-6 It was
expected that, if a patient is young, having catheter
needle scars left would lead to a negative body image. In
addition, since young patients are more active and movearound significantly, the angle of the catheter needle isliable to change, causing pain. These are assumed tohave been the reasons for the significant differences attributable to age.
No significant differences were seen in other items.
However, in terms of treatment history, only those whose
history of treatment was 10–20 years had more participants who were “dissatisfied” than “satisfied,” showing
an opposite trend. Approximately 80% of patients with atreatment history spanning 10–20 years were likely to be

Relationship between basic attributes and degreeof satisfaction with CSII therapy

The participants’ thoughts on CSII therapy: Unstructured opinions

Participants’ thoughts on CSII therapy were divided into
the following ten categories: i) gratitude for CSII therapy; ii) hopes for CSII therapy; iii) drawing a distinction
between type 2 and type 1 diabetes; iv) CSII therapy’s
unique burden on the body; v) the burden of making
monthly hospital visits; vi) a feeling of distrust in healthcare providers; vii) a sense of financial difficulty due to
medical payments; viii) a sense of distrust in high medical fees; ix) financial anxieties about the future and x)
hopes for medical advancements (Table 4).

Table 4. The participants’thoughts on CSII therapy:
Unstructured opinions
Categories

Number of data (%)

Gratitude for CSII therapy

8 (6.2)Hopes for CSII therapy

2 (1.5)

Drawing a distinction between type 2 andtype 1 diabetes

5 (4.0)

CSII therapy’s unique burden on the body

2 (1.5)The burden of making monthly hospital
visits12 (9.2)

A feeling of distrust in healthcare providers

8 (6.2)A sense of financial difficulty due to medical payments

36 (27.7)

A sense of distrust in high medical fees

18 (13.8)

Financial anxieties about the future

11 (8.5)

Hopes for medical advancements

28 (21.5)

CSII, continuous subcutaneous insulin infusion.

104

Satisfaction with CSII therapy in T1D patients

Patients’ evaluation of CSII therapy

female and in their 30s to 40s. In Japan, patients in thisage group are reported to significantly prioritize doinghousework for their family or working to earn a living
over taking care of their diabetes so their blood sugar
control tends to be erratic.7 Our study appears to show
a similar pattern because of the same structure as thatin the above report. Female patients appear to be working as co-breadwinners while raising children so as tobe able to earn a satisfactory income to sustain a living.
In Japan, generally treatment of type 1 diabetes tends toswitch to CSII therapy in the case of poor blood glucose
control by MDI therapy. Even after switching to CSII
therapy, therefore, their blood sugar control failed to improve sufficiently, which may explain the large numberof participants who answered that they were “dissatisfied.”

Judging by the basic attributes of our study participants,
many patients appear to have switched from MDI therapy to CSII therapy. Having changed to CSII therapy, thepatients commented that their blood sugar and HbAlc
levels had dropped, they suffered fewer instances ofhypoglycemia, and they acknowledged an improvementin their health. As examples of positive evaluations,they cited two things: their “gratitude for CSII therapy,”
which released them from the hassle of blood sugar
control and the pain of seeing hypoglycemia develop,
and gaining a sense of mental stability; and “hopes for
CSII therapy,” i.e., that this therapy would become morewidespread and benefit a greater number of type 1 diabetes patients. CSII therapy has been proven useful inthat it enables the maintenance of blood sugar control
using smaller doses of insulin than MDI therapy and that
it is less liable to induce hypoglycemia.6 Likewise, theresults of our study suggest that a reduction in the burden of having to adjust their insulin dose by themselves,the improvement in blood sugar and HbA1c levels, anda reduction in the incidence of hypoglycemia have led
to favorable evaluations. Regardless of the participants’thoughts about CSII therapy, however, they showed adesire to “draw a distinction between type 2 and type1 diabetes,” or, in other words, to clarify the difference
from type 2 diabetes, a disease that develops because oflifestyle habits and aging. These patients are believed tobe receiving CSII therapy while facing the psychologicalstress of getting their disease mixed up with type 2 diabetes. In addition to this psychological stress, CSII therapy has a number of drawbacks. First, it imposes a uniqueburden on the body; since the site of needle insertion islimited to the abdomen and since insulin is consistently
injected via an indwelling needle, the procedure causes
itchiness and hardening of the skin. Second, it entails
the burden of having to visit a hospital every month;even with CSII therapy, patients must be examined
monthly so the interval between hospital visits is short.
Third, it creates a sense of financial difficulty because of
medical payments; patients must take a leave of absencefrom work when receiving outpatient treatment and areburdened with increased medical costs. As revealed inthis study, patients experience adverse physical effects
that are unique to CSII therapy and experience a feelingof difficulties that are directly linked to a public life.
Another noteworthy finding was that the participants
adversely evaluated items relating to medical treatment
and social security setups for type 1 diabetes patients,
such as “distrust of high-cost medical treatments,” “distrust of healthcare providers,” and “financial anxieties
toward the future.” In Japan, patients with type 1 diabetes are eligible to receive public medical assistance up to

Relationship between the degree of satisfaction
with CSII therapy and views on diabetes treatment

A majority number of patients replied “yes, I have been
dissatisfied” when asked if they agreed with the statement “I have never been dissatisfied with the way mydoctor dealt with me.” In a preceding study, 60% of thepatients reportedly did not consult with their physiciansin spite of harboring anxieties about treatment using
insulin. Conversely, patients who had received full explanations from their physicians were reported to havea high degree of satisfaction with their treatment using
insulin.8Likewise, in our study, many patients who felt
they received insufficient responses to their questions or
explanations from physicians were believed to have answered “yes, I have been dissatisfied.” To the item “payment for medical treatments imposes a heavy financial
burden,” however, a large number of patients answered“yes” despite their being either satisfied or dissatisfied.
Regarding financial burden, it has already been suggested that the worse a patient’s diabetes becomes and themore advanced its complications, the higher the treatment fees become which adversely affects the degree ofsatisfaction with treatment, thus causing a reduction in
QOL.9 Our study also showed that many patients were
suffering from the burden of medical payments. Even
though their burden of medical payments may be very
heavy, some patients answered that they were “satisfied” with their treatment while others answered thatthey were “dissatisfied.” One item of information that
became clear in our study was that “payment for medical treatments imposes a heavy financial burden” was
not necessarily directly linked to degree of satisfaction
with the treatment. Going forward, therefore, studies ofassistance and support are required that are tailored tothe patients’ psychological and social conditions while
undergoing CSII therapy.
105

I. Nishio et al.

age 18 based on the government’s program of medical
benefits for specific childhood chronic diseases. Afterthey pass the age of 18, however, they are no longer eligible and lose medical assistance. Moreover, CSII therapy earns greater medical remuneration points than MDI
therapy, adding to the patients’ financial burden. The
current situation of healthcare providers giving insufficient explanation about the treatment, including medical
costs, and not providing sufficient information overall,is likely to result in distrust on the part of the patientsof high-cost medical treatment as well as of healthcare
providers, adding to the distress that the patients are already suffering. As a result, anxieties on the part of thepatients become more pronounced, leading to worries
about future financial insecurity. If a person develops
type 1 diabetes, a system of public medical subsidies isavailable at least during childhood; a support network
has also been established through summer camps for pediatric diabetes patients. After adulthood, however, thesupport network becomes insufficient with no system inplace to help solve problems that occur. Medical treatment is not made clearly visible.10 The same can also
be said to be found in our study. Type 1 diabetes is not
the only disease where the burden of medical payments
results in financial anxieties on the part of patients. Individuals with chronic illnesses, such as type 2 diabetes
patients who are undergoing insulin therapy and cancer
patients who receive chemotherapy, are reported toexperience financial anxieties when undergoing treatment. Type 1 diabetes patients, however, must continue
to inject insulin every day before each meal for the restof their lives, making their burden of medical payments
especially serious. In our study, the patients stated their“hopes for medical advancements,” expressing their desperate wish that low-cost insulin preparations and simpler medical and measurement devices will be developed
and approved as soon as possible, and that revolutionary
treatment that is both effective and less burdensome tothem will become available.
When comparing the results of a survey on the degree of satisfaction with treatment and the participants’unstructured comments, we found that, in the survey,
more participants answered that they were “satisfied”
than “dissatisfied.” However, many wrote in the unstructured comment space that they were “dissatisfied” with
CSII therapy. CSII therapy makes it possible to maintainblood sugar control over a long period of time, which isa huge advantage for the patients. However, it also has asignificant disadvantage in terms of cost. This is likely tohave been why we observed such mixed feelings. It has
been reported, moreover, that the respondents of Internet
surveys are not reluctant to say what they honestly feel,since this type of survey cannot identify the anonymous
respondents.11 Indeed, because this was an Internet survey, the participants are believed to have revealed theirhonest and unfiltered opinions without hesitation in the
unstructured comments space concerning their dissatisfactions with their treatment.
Proposals for nursing care

The greatest number of comments we heard from thepatients in this study pertained to the high cost of CSII
therapy. As future countermeasures, we believe support will be necessary to assist the patients to continue
undergoing this therapy with peace of mind. This might
include enhancing patient education, including the provision of information on medical expenses, encouraging
exchanges between patients, and setting up a contact
point where they feel they are welcome to ask for consultations. Although few, we also heard several patients
express their distrust of medical personnel. As a measure to counter this, it is important for nurses to actively
communicate with the patients and provide assistanceafter understanding what patients see as problematicand burdensome about CSII therapy.
Acknowledgments: We thank all patients with type 1 diabetes
who participated in this study. We would like to thank Eli Lilly
Japan K.K., for performing data collection.
The authors declare no conflict of interest.

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