Sharps Disposal Practices Among People With Diabetes in a Community Care Clinic

The primary objective of this study was to determine sharps disposal practices among people with diabetes in a community care clinic. Secondary objectives were to identify patterns of sharps use and barriers to proper use.

This prospective study was conducted at a community care clinic in western Massachusetts that offers a free diabetes self-management education and support program accredited by the Association of Diabetes Care and Education Specialists. The clinic is staffed by pharmacists with academic positions at a local university and serves individuals with prediabetes, type 1 diabetes, and type 2 diabetes. Demographics of the clinic’s patient population vary in terms of social background, education, age, mode of diabetes management, and diabetes duration.

The in-person enrollment period was open for 3 months (January to April 2019). Adults with diabetes who use sharps in their diabetes management were eligible for inclusion. Potential participants were excluded if they did not use sharps in their diabetes management. Participation in the study was voluntary, and the responses were anonymous. The institutional review board at Western New England University granted exempt-status approval before the start of the study.

Surveys were distributed to clinic patients upon arrival for an appointment; participants completed the survey after the appointment and placed it into a locked mailbox or, alternatively, returned the survey via mail using a prepaid, clinic-addressed envelope. Surveys were mailed to patients who did not have scheduled upcoming appointments.

The survey questions focused on how sharps are used and disposed of, the frequency of sharps changes, disposal training, sharps identification, and confidence in sharps disposal (Supplementary Materials). Participant demographics (age, sex, race/ethnicity, prior training, and education level) and diabetes profile (type of diabetes, years since diagnosis, and mode of management) were also collected. Descriptive statistics (means and frequencies) were reported for all variables collected.

From 23 January to 4 April 2019, 113 people were seen at the clinic. Of those, 96 (85%) were eligible for the study, and 64 (66.7%) completed and returned the survey. Surveys were mailed to 200 additional clinic patients who did not have a scheduled upcoming appointment; 25 of those (12.5%) returned the survey.

Of the total 89 respondents, the mean age was 60 years (range 29–93 years), 61.8% were Caucasian, 88.8% had type 2 diabetes, and 60.7% had a time since diabetes diagnosis ≤10 years (Table 1). Men and women responded in even proportions. Survey respondents were allowed to choose multiple methods of diabetes management, and responses about methods of diabetes management varied. Food choices, oral medications, insulin, injectable medications other than insulin, and physical activity were all included as possible methods of diabetes management.

In this study, prior sharps training was defined as training from any qualified HCP at any point since the diabetes diagnosis in either a group or one-on-one setting. Fifty-one respondents (57.3%) did not receive or were unsure of receiving sharps training, 38 (42.7%) indicated having received prior sharps training, and 12 (13.5%) noted having received training from multiple sources.

Respondents reported sharps use and disposal practices, which were then stratified by whether they had reported receiving prior training (Table 2). Twenty-three respondents (25.8%) discarded used sharps without a designated sharps container, and 6 (6.7%) reported using an improper container for sharps material (i.e., not leak proof or puncture resistant). Thirty-three respondents (37.1%) properly disposed of sharps containers at sharps disposal facilities, whereas 11 (12.4%) reported keeping full sharps containers at home because they did not know how to dispose of the containers, and 20 (22.5%) disposed of sharps containers in their home garbage receptacle.

Eighty-eight respondents (99.9%) reported using lancets in their diabetes management, and 54 (61.4%) changed lancets after every use. Of the patients using lancets, 68.4% who had received prior sharps training changed their lancet after every use compared with 55.8% of those with no prior training and 57.1% of those who were unsure whether they received training. Fifty respondents (56.12%) reported using pen needles in their diabetes management, and 40 (80.0%) changed pen needles after every use. Of the patients using pen needles, 82.6% who had received prior sharps training changed their pen needles after every use compared with 79.1% of those with no prior training and 66.7% of those who were unsure of training. Fifteen respondents (16.85%) reported using syringes in their diabetes management, of whom 10 (66.7%) changed syringes after every use. Of the patients using syringes, 80% who had received prior sharps training changed their syringe after every use compared with 55.6% of those without prior training and 100% of those who were unsure of training.

Of the 89 respondents, 35 (39.3%) reported not changing sharps after every use. Of those, 17 (48.6%) cited perceived waste with single use, 17 (48.6%) cited perceived safety of reusing, 10 (28.6%) cited cost concerns, 7 (20.0%) cited disposal hassles, and 5 (14.3%) cited only changing sharps when using them hurt as reasons for not changing sharps after every use (Figure 1). Three respondents reported an accidental needlestick event in their household as a result of sharps disposal.

Respondents were asked to identify sharps from a list of potential items (Table 3). Of the 89 respondents, 81 (91.0%) identified lancets, 60 (67.4%) identified pen needles, 45 (50.6%) identified syringes, 26 (29.2%) identified lancing devices, 20 (22.5%) identified glucagon-like peptide 1 receptor agonist pen needles, and 7 (7.9%) identified insulin delivery devices as sharps.

Additionally, the respondents were asked to indicate their confidence in proper sharps disposal on a scale ranging from 1 to 10, with 1 being the least confident and 10 being the most confident (Table 4). The majority of respondents rated their confidence in sharps disposal as a 10; of the 42 (47.2%) who rated their confidence as a 10, 21 (50.0%) had prior sharps training, 19 (45.2%) did not have prior training, and 2 (4.8%) were unsure of prior training.

Proper sharps disposal is widely recognized as necessary for the safety and well-being of the community. Numerous sharps disposal studies have been conducted in health care settings, and the results of these studies have prompted tighter, more standardized regulation and training promoting safe sharps waste management in health care settings (10).

For consumers, training may include information about where to obtain sharps disposal containers or how to make appropriate containers, how to find drop-off locations for full containers, and descriptions of the proper handling and disposal of sharps materials. However, there is no standardized training mandated by federal or Massachusetts state laws or regulations for consumers who use and dispose of sharps (2). As a result, there is inconsistent training on the proper usage and disposal of sharps for consumers, including people with diabetes.

Of the 89 survey respondents in our study, less than half (42.7%) reported receiving sharps disposal training at any point after their diabetes diagnosis, illustrating a lack of training standardization. Although more than half of the respondents (65.2%) reported using a proper leak-proof, puncture-resistant container for sharps materials, only 37.1% reported properly disposing of the sharps container at a sharps take-back location, despite state regulations mandating this practice. Furthermore, 11 respondents (12.4%) reported that they retained sharps containers at home because they were unsure about where to dispose of them. This finding suggests that Massachusetts sharps take-back facilities are underutilized, likely because of a lack of standardized sharps training in the community.

Survey results indicate that individuals with prior sharps training reported using a proper, designated sharps container more frequently than those without training (81.6 vs. 58.1%). Furthermore, those with prior sharps training more frequently reported discarding used sharps containers appropriately at a designated sharps take-back facility than those without training (50.0 vs. 30.2%). These results are consistent with those demonstrated by Huang et al. (7) in 2018. However, there are apparent gaps in proper sharps use and disposal knowledge, even among individuals reporting prior sharps training. Of those with prior training, 13.2% reported throwing sharps directly into the garbage without a container, and 28.9% reported disposing their filled sharps container into a home receptacle; both methods of disposal are potentially dangerous to individuals handling the sharps materials and are against Massachusetts law.

In addition to the primary findings, secondary findings demonstrate that respondents with prior sharps training more frequently report changing sharps materials after every use than those without prior sharps training. However, there is still a significant knowledge gap among respondents with prior training, as 31.6% of respondents using lancets reported not changing them after every use, 17.4% of those using pen needles reported not changing them after every use, and 20.0% of those using syringes reported not changing them after every use. These findings may indicate that repeated training and education on sharps use is necessary to ensure proper sharps use and disposal over time.

The two most common reasons respondents gave for not discarding their used sharps after every use were perceived safety of reusing sharps (48.6%) and perceived waste of using sharps a single time (48.6%) (Figure 1); this finding illustrates gaps in knowledge of proper sharps usage. The third most commonly reported reason for reusing sharps was cost concerns (28.6%).

Some diabetes supplies such as lancets and lancing devices are available as over-the-counter (OTC) products or through health insurance plans. Insurance options were not surveyed; however, it is likely that some participants are Medicare or Medicaid recipients. Medicare Part B covers 80% of lancets and lancing devices for individuals with diabetes, once the deductible is met (11). Medicaid coverage for diabetes supplies varies by state (12). The average OTC retail price of a lancet is $0.134. The average OTC retail price of a 30-day supply of pen needles ranges from $54 to $74, and a 30-day supply of syringes can cost from $2 to $40 (13). Affordable sources of sharps materials should be determined for each person.

The Centers for Disease Control and Prevention recommends that used lancets be disposed of “at point of use” and that lancing devices never be shared (14). The American Diabetes Association (ADA) advises against reusing sharps for people who are actively ill, are immunocompromised, or have open hand wounds (15). The ADA also strongly recommends that sharps materials never be shared. A case report (16) described a 71-year-old woman with metastatic squamous cell carcinoma and insulin-dependent type 2 diabetes with a necrotic lesion on her lower abdomen; the lesion was revealed to be at the site of repeat insulin injections with reuse of needles. Zabaleta-Del-Olmo et al. (17) conducted a meta-analysis of 25 studies to determine the safety of needle reuse for subcutaneous insulin injection. Five studies showed no association between infection at the site of injection and reuse of needles, but five studies showed an association between lipohypertrophy and needle reuse (17). The researchers concluded that there is no clear scientific evidence for or against needle reuse for subcutaneous injection and that further research is needed to determine whether the practice is safe.

Respondents were also asked to identify sharps from a provided list (Table 3). Those with prior sharps training correctly identified sharps items more frequently than those without prior training. However, many respondents, including those with prior training, missed the fact that items such as lancing devices, syringes, GLP-1 agonist pen needles, and insulin delivery devices are considered sharps. These missed identifications may be the result of a lack of standardized sharps training.

Most respondents indicated a high level of confidence in their knowledge of sharps disposal practices, with a greater percentage of those reporting prior sharps training reporting a higher confidence level than those without prior training (Table 4). Interestingly, the majority of respondents reported confidence in their sharps disposal practices, but earlier results demonstrate that improper disposal practices are occurring at a frequent rate, even among those with prior training (Table 2). Furthermore, 5.3% of those with prior sharps training reported feeling the least confident with sharps disposal practices, indicating that prior training does not necessarily correlate to increased confidence in sharps practices.

Respondents with prior sharps disposal training were more likely to use a designated container (86.8 vs. 62.8%) but, because of the small sample size, the result did not reach statistical significance (P = 0.489). In addition, respondents with prior training were more likely to use a facility for container disposal (50.0 vs. 30.2%); this result also did not approach statistical significance because of the small sample size (P = 0.103).

Results from this study indicate that significant gaps exist in proper sharps use and disposal practices, regardless of prior sharps training. These findings suggests that, although proper sharps training was helpful in promoting proper sharps practices in this population, gaps in the sharps training processes still exist and need to be addressed; more standardized training is needed for patients who use sharps in their diabetes management. Even for people who did receive prior sharps training, the training may not have been focused enough or a refresher training course may be required periodically to ensure continued proper sharps usage and disposal. Additionally, affordable sources of sharp materials should be addressed at training sessions. Further studies are needed to elucidate which specific education methods will best improve community sharps disposal practices.

Enrollment in this study was initially open for 3 months during the winter season in New England. Patients who scheduled and kept their appointment during the enrollment period were invited in person to participate in the study; thus, inclement weather and resulting missed appointments could have contributed to the number of respondents ultimately included in the study. Surveys were mailed to patients without an upcoming scheduled appointment after the in-person enrollment period, but the response rate to mailed surveys was low (12.5%). Outdated addresses could have contributed to the low response rate and, ultimately, to the small sample size of the study (n = 89).

Because participation was voluntary and survey-based, selection bias must be considered as a limitation. Furthermore, the vast majority of the population surveyed had type 2 diabetes and were older in age. Additionally, the survey should have included a question to ascertain the number of sharps materials used per day by individual respondents. Because of these limitations, results from this dataset may not be appropriately extrapolated to other diabetes communities. Thus, broader and/or larger future studies are needed to build on these findings.

The results from this survey indicate the need for focused sharps use and disposal training for every person using sharps in diabetes management. Although prior sharps training appears to mitigate improper sharps usage and disposal practices, comparative results indicate apparent gaps across all prior training levels; thus, even individuals with prior sharps training may need further education. Additionally, the responses collected in this study highlight current sharps disposal practices that are inconsistent with federal and state regulations and are potentially dangerous for individuals handling improperly discarded sharps. These results may assist in the development of targeted sharps use and disposal education resources.

No potential conflicts of interest relevant to this article were reported.

This study was funded by the College of Pharmacy and Health Sciences at Western New England University.

M.S.C. collected and analyzed data and wrote the manuscript. K.A.P. and K.L.C. contributed to the discussion and reviewed/edited the manuscript. D.C.D. analyzed data and contributed to the discussion. K.S. collected data. N.S. analyzed data. M.S.C. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

This article contains supplementary material online at https://doi.org/10.2337/figshare.19750306.