Socioeconomic status and diabetes technology use in youth with type 1 diabetes: a comparison of two funding models

Higher suicide risk in type 1 diabetes compared to cancer and the general population in Korea

BACKGROUND

People with diabetes have increased suicide risk. However, it is unclear whether those with type 1 diabetes (T1D) have a higher risk than those with cancer, a disease associated with significant psychological stress and suicide risk.

OBJECTIVES

To evaluate suicide risk among adults with T1D compared to matched cohorts of patients with cancer and the general population.

METHODS

This population-based matched-cohort study examined adults aged ≥19 years (45,944 with T1D and 45,944 with cancer matched for age, sex, and index year) using data from the Korean National Health Insurance Database for January 2009-December 2015 and including 229,720 matched controls without diabetes or cancer (1:5). Composite suicide outcomes were death by suicide or hospitalization for a suicide attempt (intentional self-harm, fatal toxic substance, toxic effect of carbon monoxide, psychotropic medication, wrist laceration, fall, and asphyxia).

RESULTS

Participants had a median age of 62 years and a median follow-up duration of 10.3 years. T1D was significantly associated with an increased risk of composite suicide outcomes (adjusted hazard ratio [aHR] = 2.02; 95% confidence interval [CI] = 1.87-2.19) compared to controls. Individuals with T1D had significantly higher composite suicide outcome risk than patients with cancer (1:1) (aHR = 1.75; 95% CI = 1.55-1.97). Younger (Age < 50) and lower-income patients with T1D had a higher suicide risk than those without diabetes or cancer.

CONCLUSION

This nationwide study demonstrated a significant association between T1D and increased suicide risk compared to the general population and patients with cancer. This underscores the importance of mental health screening and targeted interventions for this population.

Understanding inequities in access to diabetes technologies in children and young people with type 1 diabetes: Qualitative study of healthcare professionals' perspectives and views

AIMS

We explored healthcare professionals' perceptions and understandings of the factors and considerations underlying inequities in technology access in children and young people (CYP) with type 1 diabetes.

METHODS

We interviewed (n = 29) healthcare professionals working in paediatric diabetes in England recruited from (n = 15) purposively selected sites. We analysed data thematically.

RESULTS

Interviewees highlighted multiple, often overlapping barriers to accessing technology faced by CYP with type 1 diabetes from deprived and/or ethnic minority backgrounds. They described the impacts of deprivation on technology uptake, together with the complex social, ethnic and cultural factors that could also reinforce disparities in technology access. Interviewees further highlighted staffing shortfalls as a significant barrier to supporting CYP to use technology, especially those from under-represented groups who they perceived as requiring more staff time to be trained to use technology. While interviewees suggested that unconscious bias has become less prominent, they reported being less likely to recommend technology (especially pumps) to CYP/caregivers who they feared would not use it safely and effectively (e.g. those with low literacy levels). Interviewees also highlighted geographical variability in the technology commissioning process (a 'postcode lottery').

CONCLUSIONS

Our findings suggest that without targeted interventions, technology inequities may continue to persist amongst CYP from the most and least deprived areas and from white and ethnic minority groups in the United Kingdom. Additionally, our findings suggest that closing the technology gap will require large-scale governmental and health policies aimed at fostering socioeconomic, ethnic and cultural equality alongside targeted measures to improve technology accessibility.

The Impact of Public Policy on Equitable Access to Technology for Children and Youth Living with Type 1 Diabetes in British Columbia, Canada

Objective: Structural inequities impede technology uptake in marginalized populations living with type 1 diabetes (T1D). Our objective was to describe hemoglobin A1c (HbA1c), time in range (TIR), and pump use to evaluate the impact of a universal funding policy for continuous glucose monitoring (CGM) across levels of deprivation in children with T1D in the Canadian province of British Columbia (BC). Methods: Patients with T1D and at least one outpatient visit after June 10, 2020 (1-year before universal CGM funding) who were enrolled in the BC Pediatric Diabetes Registry were included (n = 477). The Canadian Index of Multiple Deprivation (quintile 1 = least deprived; quintile 5 = most deprived) was determined using postal code. Mixed effects models were used to describe HbA1c, TIR, and pump use, and an interrupted time series generalized additive model estimated the change in CGM use pre- and postintroduction of universal coverage. Results: No differences were observed among the five levels of deprivation for HbA1c and TIR; however, for residential instability, those with the highest level of deprivation had a lower probability of pump use (-18.9%, 95% confidence interval [CI] = -26.1% to -11.7% for quintile 5 vs. 1). There was an increase in CGM uptake across all levels of deprivation 1-year after introduction of universal CGM funding. For example, the difference in sensor use from the most to least deprived situational group was -21.0% (-35.4%, -6.6%) at the time of universal coverage and shrank to -4.6% (-21.6%, 12.4%) after 12 months of coverage. However, an equity gap in CGM use persisted between the least and most deprived groups (-21.9, 95% CI = -34.5 to -9.4 for quintile 5 vs. 1 in economic dependency). Conclusions: Universal coverage of CGM improved uptake; however, equity gaps persisted. More research is needed to explore nonfinancial barriers to diabetes technology use in marginalized populations.

Developing a Quality Improvement Framework to Enhance the Health System User Experience for Individuals Living With Type 1 Diabetes: The Reshape T1D Study

INTRODUCTION

User experience design aims to create products and services that are accessible, usable, and enjoyable. The Reshape T1D study aims to apply these principles to understand how individuals living with T1D interact with and experience healthcare to inform T1D clinical quality improvement.

METHODS

Using a community-based participatory research design, we involved four patients and four clinicians as co-researchers throughout the research. A questionnaire and virtual semi-structured interview were applied across a purposeful sample of 41 adults living with T1D across Alberta, Canada, between September 2021 and May 2022. Audio recordings were transcribed verbatim and de-identified before coding. Thematic analysis was conducted on coded participant discourse through multiple coders.

RESULTS

Participants indicated the need for a centralized hub that provides consistent, reliable, and up-to-date T1D education and resources and an emphasis on access to mental health resources within T1D care settings. Providing greater flexibility for appointment types (ie. in-person, virtual, etc.) and after-hours access contributed to better self-management and prevented emergency room visits. Participants desired a choice as to who comprises their T1D care team and for teams to address patient needs specific to their reality. We identified that medical trauma had long-term impacts on perceptions of healthcare and contributed to a reluctance to seek future care. Women expressed challenges in discussing reproductive health with their clinicians. Diabetes online communities provide an adjunct to clinical care through peer support. Cost and access to the latest technology are ongoing barriers for many participants, especially concerning publicly funded programmes that use advanced insulin pump therapy, continuous glucose monitoring, and automated insulin delivery systems. A quality improvement framework emerged through data analysis, and findings were synthesized into actionable recommendations for ongoing clinical quality improvement.

CONCLUSION

Our findings highlight how important health system user suggestions are for more equitable, accessible, and empathetic healthcare for individuals living with T1D. Further work is needed to explore health system user experiences with clinicians and healthcare administrators to effectively carry out T1D clinical quality improvement.

Real-world glycaemic outcomes in children and young people on advanced hybrid closed-loop therapy: A population-based study in Western Australia

AIMS

To evaluate real-world glycaemic outcomes in children with type 1 diabetes (T1D) commencing advanced hybrid closed loop therapy (AHCL) and to explore these outcomes based on the cohort's clinical and socioeconomic characteristics.

METHODS

A single-centre, population-based retrospective study in children commencing AHCL (Smart Guard, Control IQ, CamAPS) with minimum 70% data from two-weeks CGM pre-AHCL was conducted between December 2021 and June 2023 in Western Australia. CGM metrics (time in range (TIR) 3.9-10 mmol/L, time below range (TBR) < 3.9 mmol/L, glucose management indicator (GMI)) were analysed at baseline, monthly and 6 months. HbA1c at baseline and 6 months were also collected. The proportion meeting glycaemic targets of TIR > 70%, TBR < 4% and GMI < 7.0% were determined. Change in TIR from baseline to 6 months was examined by the following characteristics: %TIR, age group and Index of Relative Socioeconomic Disadvantage (IRSD) of residential postcode.

RESULTS

CGM data of 309 children, mean (SD) age 12.4 (3.2) years were analysed. Glycaemia improved from baseline to 6 months with (mean) TIR +8% (95% CI 7, 9; P ≤ 0.001), GMI -0.3% (95% CI -0.3, -0.2; P < 0.001) and (median) TBR -0.3% (95% CI -0.4, -0.1; P < 0.001). Proportion meeting glycaemic targets increased from 13.3% at baseline to 30.6% at 6 months. Improvement in TIR did not differ based on age group or IRSD Quintile. Greater increase in TIR was seen in those with lowest TIR at baseline (+20.9%, -0.2%; P < 0.001 for baseline TIR < 40%, >70%). There was a 0.27% reduction in HbA1c in 6 months (n = 116) (P < 0.001).

CONCLUSIONS

AHCL improves glycaemia, irrespective of age and socioeconomic characteristics, with greatest changes seen in those with lowest baseline TIR.

Contributions of digital technologies for resilience capacity in a type 1 diabetes transition clinic: A qualitative study

A type 1 diabetes (T1D) transition clinic in Sydney, Australia, provides age specific care for young adults (aged 16-25 years) and for adults (aged 21 years and above), and has reported improved clinical outcomes post transition to adult care over a 21-year period. This study investigated the contribution of digital technology to long-term resilient capacity of the clinic. Clinic observations and interviews with eight providers and 17 young adults were conducted. Using a framework to analyze resilient capacity in healthcare, seven strong themes emerged from the data: Leadership, Involvement, Communication, Coordination, Risk Awareness, Competence and Alignment with three themes, Structure, Learning and Facilitators also supported. Patient service adaptations included offering out of hours appointment times and telehealth to accommodate young adults' availability. This study provides evidence for the important role that digital technologies contribute to a system of care with capacity for resilience. Our findings contribute to the understanding of the factors needed to support young adults with T1D and may be valuable to inform models of care for young adults living with other chronic health conditions.

Disparities in Diabetes Technology Uptake in Youth and Young Adults With Type 1 Diabetes: A Global Perspective

Globally, nearly 9 million people are living with type 1 diabetes (T1D). Although the incidence of T1D is not affected by socioeconomic status, the development of complications and limited access to modern therapy is overrepresented in vulnerable populations. Diabetes technology, specifically continuous glucose monitoring and automated insulin delivery systems, are considered the gold standard for management of T1D, yet access to these technologies varies widely across countries and regions, and varies widely even within high-income countries. This review focuses on disparities in diabetes technology use among adolescents and young adults with T1D, barriers to access and use, and summarizes common themes emerging across countries and regions. We conducted a survey among medical technology manufacturers and physicians in various countries across diverse geographical regions and performed extensive literature searches. Across all countries and regions, economic barriers stand out as the largest and most common barriers, either preventing market penetrance of technology into a country or limiting its access to the individual with diabetes due to high out of pocket costs. Other common barriers include structural or accessibility barriers, such as stringent eligibility requirements by insurance providers, regardless of whether the insurance was private or government-based, and provider/individual level barriers. Based on the evidence presented, we suggest the need for a joint effort involving governments, private health insurers, technology manufacturers, and healthcare providers to address the global disparities of diabetic technology utilization and ensure equitable access for all individuals living with T1D worldwide.

Do hybrid closed loop insulin pump systems improve glycemic control and reduce hospitalizations in poorly controlled type 1 diabetes?

OBJECTIVES

Hybrid closed-loop (HCL) systems improve glycemic control in type 1 diabetes mellitus (T1D), but their effectiveness in young, poorly controlled populations is not established and requires study.

METHODS

A pre-post study was performed using electronic health records of patients 3-24 years with baseline HbA1c≥9 % prescribed HCL within the New York City Health+Hospitals System assessing HbA1c levels and hospitalizations before and after HCL initiation and factors associated with achieving HbA1c<9 % after HCL initiation.

RESULTS

Of 47 children and adolescents who met inclusion criteria, 4.68 % female, 95.72 % non-White, and 82.22 % covered by public insurance, with a baseline average HbA1c 10.6 % (2.28 IQR). The most prevalent pump type was Omnipod 5 (70.21 %). The HbA1c was significantly lower in the postperiod than baseline (HbA1c before=median 10.6 (IQR2.28), HbA1c after=median 9.33 (IQR 2.97), difference 1.00 (IQR 1.64), p<0.05) with a decrease in median diabetes-related hospitalizations (preperiod 1.00 (IQR 1.00), postperiod 0.00 (IQR 1.00), difference -1.00, IQR 2, p<0.05). Lower baseline HbA1c levels made reaching HbA1c<9 % more likely. Multivariable analysis showed that the odds of having HbA1c of <9 % was 2.1 times less likely for every one point increase in baseline HbA1c and 12.5 times less likely for those with a pump at (p<0.05).

CONCLUSIONS

HCL therapy improved glycemic control and decreased diabetes-related hospitalizations in youth with poorly controlled T1DM. Higher baseline HbA1c levels predicted less success with HCL therapy so those who stand to benefit most benefit least.

Single-arm, first-in-human feasibility study results for an ultra-low-cost insulin pump

BACKGROUND

Use of Continuous Subcutaneous Insulin Infusion (CSII) has been shown to improve glycemic outcomes in Type 1 Diabetes (T1D), but high costs limit accessibility. To address this issue, an inter-operable, open-source Ultra-Low-Cost Insulin Pump (ULCIP) was developed and previously shown to demonstrate comparable delivery accuracy to commercial models in standardised laboratory tests. This study aims to evaluate the updated ULCIP in-vivo, assessing its viability as an affordable alternative for those who cannot afford commercially available devices.

METHODS

This first-in-human feasibility study recruited six participants with T1D. During a nine-hour inpatient stay, participants used the ULCIP under clinical supervision. Venous glucose, insulin, and β-Hydroxybutyrate were monitored to assess device performance.

RESULTS

Participants displayed expected blood glucose and blood insulin levels in response to programmed basal and bolus insulin dosing. One participant developed mild ketosis, which was treated and did not recur when a new pump reservoir was placed. All other participants maintained β-Hydroxybutyrate < 0.6 mmol/L throughout.

CONCLUSION

The ULCIP safely delivered insulin therapy to users in a supervised inpatient environment. Future work should focus on correcting a pump hardware issue identified in this trial and extending device capabilities for use in closed loop control. Longer-term outpatient studies are warranted.

TRIAL REGISTRATION

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12623001288617) on the 11 December 2023.

Improved Glycemic Outcomes With Diabetes Technology Use Independent of Socioeconomic Status in Youth With Type 1 Diabetes

OBJECTIVE

Technology use in type 1 diabetes (T1D) is impacted by socioeconomic status (SES). This analysis explored relationships between SES, glycemic outcomes, and technology use.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis of HbA1c data from 2,822 Australian youth with T1D was undertaken. Residential postcodes were used to assign SES based on the Index of Relative Socio-Economic Disadvantage (IRSD). Linear regression models were used to evaluate associations among IRSD quintile, HbA1c, and management regimen.

RESULTS

Insulin pump therapy, continuous glucose monitoring, and their concurrent use were associated with lower mean HbA1c across all IRSD quintiles (P < 0.001). There was no interaction between technology use and IRSD quintile on HbA1c (P = 0.624), reflecting a similar association of lower HbA1c with technology use across all IRSD quintiles.

CONCLUSIONS

Technology use was associated with lower HbA1c across all socioeconomic backgrounds. Socioeconomic disadvantage does not preclude glycemic benefits of diabetes technologies, highlighting the need to remove barriers to technology access.

AMCP Market Insights Health Plan Best Practice: Implementing continuous glucose monitoring to improve patient outcomes in diabetes

Diabetes is a complex chronic condition that affects the body's ability to produce or use insulin effectively, resulting in elevated blood glucose levels. It is associated with various complications and comorbidities, significantly impacting both individuals and the health care system. Effective management involves a combination of lifestyle adjustments, medication adherence, monitoring, education, and support. The expanding use of continuous glucose monitoring (CGM) has been transformative in diabetes care, providing valuable real-time data and insights for better management. To understand the opportunity for health plans to support improved patient outcomes with CGM, AMCP sponsored a multifaceted approach to identify best practices consisting of expert interviews, a national payer survey, an expert panel workshop with clinical experts and managed care stakeholders, and a national webcast to communicate the program findings. This article summarizes current evidence for CGM to support managed care and payer professionals in making collaborative, evidence-based decisions to optimize outcomes among patients with diabetes. In addition, this review also presents the findings of a national payer survey and describes expert-supported health plan best practices around coverage and access to CGM.