Endocrinology Group Calls for Better Insulin-Pump Training

Miriam E. Tucker

May 28, 2014

The American Association of Clinical Endocrinologists (AACE) is calling for better training of both patients and providers in the use of insulin pumps.

The recommendation is included in a new consensus statement on insulin-pump management, published in the May issue of Endocrine Practice. In it, AACE updates its 2010 guidance with new information about technological advances, expanded recommendations for pump use in children and pregnant women, and use in hospital settings and calls for improved education of emergency-room and school personnel.

When used correctly — and increasingly in conjunction with continuous glucose monitoring — insulin pumps can provide more convenient insulin delivery for patients and may improve blood glucose control. But AACE is concerned that both patients and providers often lack appropriate expertise to use the devices.

Unlike in Europe, there is no official requirement for medical supervision of pump use in the United States, nor is there a certifying process for initiation of pump use by clinicians or facilities.

"It's just amazing to see how many patients are put on pumps who have not been properly trained and how cursory the training is for many patients. You can only learn so much the first time around. There is no concerted effort to make sure patients stay current....This is a call for action," AACE president-elect George Grunberger, MD, founder of the Grunberger Diabetes Institute, Bloomfield Hills, Michigan, told Medscape Medical News.

The "ideal" pump candidate, according to the statement, is a patient with type 1 diabetes mellitus or an intensively managed insulin-dependent patient with type 2 diabetes who is already performing 4 or more insulin injections and 4 or more self-monitored blood glucose (SMBG) tests daily. And both patient and provider must be motivated and willing to perform the work needed to use the pump.

"We want to get the point across that insulin pumps work well when used by the right people in the right setting. We tried to make clear this is not for everyone. But for people who get it, both on the patient side and the provider side, it's a wonderful tool to manage diabetes," Dr. Grunberger noted.

Pump Use Increasing Dramatically

The number of people with both type 1 and type 2 diabetes using insulin pumps in the United States has risen dramatically in recent years, with latest estimates at about 375,000 type 1 users in 2007 — about 20% to 30% of all patients with this type of diabetes — up from approximately 130,000 in 2002. The total number of pump users today has been estimated at between 350,000 and 515,000.

And that's against a backdrop of just 2000 or so physicians who prescribe pumps, a minority even of endocrinologists.

This is due to the enormous amount of work involved in helping patients adjust pump settings — increasingly in conjunction with continuous glucose monitor data — said Dr. Grunberger, without compensation for the extra time spent, which is a major barrier.

"There are a limited number of experts, and no way for patients to get the full benefit because of the way our healthcare system exists," he commented.

The statement calls for greater uniformity in insulin-pump training and of retraining when pumps are upgraded. "We want make sure the patients are selected well, the providers are trained, and that there's an infrastructure to allow people to get the full benefit from those devices," he explained.

Another major problem, addressed in 2010 and again in the current statement, is that Medicare currently doesn't pay for continuous glucose monitoring at all and pays for insulin pumps only for type 1 diabetes patients.

Thus, type 2 patients who require intensive insulin therapy and who may have been well-managed on pumps for decades are forced to go back to multiple daily injections when they turn 65.

"[Pumps are] just a different way to provide intensive insulin. In this situation, the distinction between type 1 and type 2 is irrelevant....The number [of type 2 diabetes patients on pumps] is relatively small, but it's still thousands of patients who are suffering because of these [Centers for Medicare & Medicaid Services] CMS decisions," Dr. Grunberger stressed.

Also discussed is the 2010 improvement initiative focusing on the safety of external infusion pumps, including insulin pumps, by the US Food and Drug Administration. The FDA collects thousands of adverse-event reports related to pumps every year, but it's often difficult to determine whether the fault rests with the device or the user.

The AACE statement points out that "open-source insulin-pump software" should make it easier for manufacturers to correct product software issues.

Dr. Grunberger advised physicians: "It's very important to appreciate that pumps are evolving, and the devices are getting more and more sophisticated. You need that infrastructure if you want to get into the pump business, and [be sure that] you can provide 24/7 coverage for your patients."

And, he emphasized, for those who choose not to take on pump use as part of their practices, "Refer your patients to the places that can provide the best care."

In another statement expected to come out this summer, AACE will address continuous glucose monitoring use along with SMBG monitoring.

Dr. Grunberger has received speaker honoraria from Amarin, Janssen, Merck, Sanofi, Santarus, Takeda, and Valeritas. He has received research support from Bristol-Myers Squibb, Eli Lilly, and Novo Nordisk.

Endocr Pract. 2014;20:464-489. Article

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