In Pediatric T1D, Race, Income, & Insurance Type Remain Significant Barriers to Insulin Pump Use

Estelle Everett, MD, MHS

Despite an emphasis in recent years on improving the uptake of new diabetes technologies, new research presented at the Endocrine Society’s annual meeting (ENDO 2022) paints a grim picture related to the uptake of insulin pumps in pediatric patients with type 1 diabetes across different racial and ethnic backgrounds.

An analysis of data from the SEARCH for Diabetes in Youth study, results of the study detail the increase in CGM uptake from 2001-2019, with results providing evidence of significant improvements in terms of overall uptake, but also pointing to a lack of improvements among certain patient groups, including Black patients, those using public insurance, and those with lower household incomes.

"We found there is a huge divide in who actually has access to insulin pumps," said lead investigator Estelle Everett, MD, MHS, of the David Geffen School of Medicine at University of California, in a statement. “Racial-ethnic minority groups and those of lower socioeconomic status still have unequal access to this very beneficial management tool. This is really concerning because these groups have more challenges managing their diabetes and have higher risk of complications. Changes in the approach to diabetes care and health policies are needed to ensure equal access to this life-changing diabetes device."

Nearly 50 years removed from the invention of the first insulin pump, the conversation has shifted from the potential benefits to eliminating barriers preventing optimized uptake of these devices. As the prevalence of pump use has increased, an understanding of contemporary barriers to insulin pump access stands to have a tangible impact on patient-level care and diabetes management as a whole. With this in mind, Everett and a team of colleagues from institutions across the US conducted the current study with the intent of evaluating how inequities in insulin pump use among pediatric patients with type 1 diabetes may have increased or diminished over time.

To do so, investigators designed their study to leverage data from the SEARCH for Diabetes in Youth study in order to perform a serial cross-sectional analysis to assess changes in insulin pump between 2001-2005, 2006-2010, 2011-2015, and 2016-2019. Patients of interest for the analyses were participants aged 19 years or less with type 1 diabetes. Subgroups of interest for the analysis were defined by racial and ethnic group, health insurance, household income, and formal parental education. For the purpose of analysis, multivariable generalized estimating equations with a binomial distribution were used to assess the probability of insulin pump use, and models were further adjusted for the other predictors, including age, diabetes duration, and clinic site, with clustering for individuals.

Initial analysis demonstrated the overall prevalence of insulin pump use had increased among pediatric patients with type 1 diabetes from 30% in 2001-2005 to 58.3% in 2016-2019. When compared to non-Hispanic White patients, a statistically significant increase in prevalence of pump use among Hispanic patients, with the adjusted odds ratio (OR) increasing from 0.08 (95% CI, 0.01-0.63) in 2001-2006 to 0.65 (95% CI, 0.48-0.87) in 2016-2019 (P=.004). However, the OR for Black patients (P=.864) and patients of other races (P=.439) did not change over the course of the study period.

In additional analyses, results demonstrated those with some high school education (OR, 0.38 [95% CI, 0.30-0.48]; P=.160) or a high school degree (OR, 0.69 [95% CI, 0.57-0.82]; P=.894) were less likely to be using an insulin pump when compared to their counterparts with a bachelor’s degree or more and this did not change over time. When compared to their counterparts with private insurance, those with public health insurance were less likely to be using an insulin pump and this did not change over time (OR, 0.84 [95% CI, 0.68-1.03]; P=.815). Investigators also pointed those with an annual household income below $25,000 (OR, 0.43 [95% CI, 0.34-0.54]; P=.937), $25,000-$49,000 (OR, 0.57 [95% CI, 0.46-0.71]; P=.870), and $50,000-$74,999 (OR, 0.80 [95% CI, 0.65-0.97]; P=.821) were less likely to be using an insulin pump than those with an annual household of $75,000 or more and this did not change over the course of the study period.

“Inequities in access to diabetes technologies are unacceptable because everyone deserves the opportunity to improve their diabetes health," Everett added. "Studies that evaluate barriers and test interventions to improve technology access are needed to address the persistent inequities in diabetes care."

This study, “Assessing Longitudinal Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes,” was presented at ENDO 2022.