Insulin Pumps Underused in Kids With Type 1 Diabetes

Miriam E Tucker

November 09, 2015

Insulin-pump therapy is associated with improved glycemic control in children and adolescents with type 1 diabetes, yet is used by less than half of youth, even in some of the world's richest countries, a new study has found.

The results, from a 2011–2012 data analysis of a number of large pediatric type 1 diabetes registries in the United States, Germany/Austria, and England/Wales, were published online November 7 in Diabetologia by pediatric endocrinologist Jennifer L. Sherr, MD, of Yale University, New Haven, Connecticut, and colleagues.

"When these data were generated, it was shocking to me to see that less than 50% of our youth are on pumps....It's so discordant with what has come out from consensus statements about the kids who could benefit from pump therapy," Dr Sherr told Medscape Medical News.

Overall insulin-pump use was lower among ethnic minorities than whites and was higher in girls than boys. Pump use also varied by age.

In all three regions combined, average HbA1c levels were 8.0% for pump users, significantly lower than the 8.5% among insulin-injection users (P < .001).

"It really is a call to arms that we all need to be doing better....We need to think more broadly about who is a pump candidate and make sure we're providing equal access regardless of age, ethnic status, or gender," she asserted.

Dr Sherr noted that the findings are particularly worrisome given that insulin pumps are a decades-old technology that are now increasingly used in conjunction with continuous glucose monitors as part of integrated systems, with research rapidly advancing to develop software to link the two devices to provide closed-loop automated insulin delivery or a so-called "artificial pancreas."

"We're on the edge of a revolution. Companies are walking down the path toward an artificial pancreas. How do we make sure our youth don't get left behind? If we're not doing well with technologies that have been around since 1978, how are we going to do with things that come out in 2015? People can get a new phone, but not a new pump? It's sort of crazy to me."

Kids With Diabetes in the United Kingdom Do Far Worse

The situation is particularly striking in the United Kingdom, where just 14% of the 14,457 participants in the English/Welsh National Paediatric Diabetes Audit were using insulin pumps in 2011 to 2012, compared with 47% of 13,755 participants in the US Type 1 Diabetes (T1D) Exchange and 41% of 26,198 participants in the German/Austrian Prospective Diabetes Follow-up Registry (P < .001).

Diabetes control among youth in the United Kingdom was dramatically worse, with a mean HbA1c of 8.9%, compared with 8.3% and 8.0% in the United States and Germany/Austria, respectively (P < .001).

This could partially be because of guidance from the UK National Institute for Health Care and Excellence (NICE), which advises that insulin pumps be considered for children younger than 12 years only if multiple daily injections are impractical or inappropriate and which recommends pumps only for those older than 12 years with disabling hypoglycemia or if HbA1c remains above 8.5% on injection therapy.

These limitations do not exist in the other countries, the authors note.

"The findings in the article are not surprising and merely confirm what has been happening in the United Kingdom over many years," according to Peter Hindmarsh, MD, professor of pediatric endocrinology and divisional clinical director of pediatrics and adolescent medicine at University College London Hospitals, United Kingdom.

But the problem isn't simply because of the NICE guidelines, he told Medscape Medical News. "Rather, it represents the fragmented care that takes place in the United Kingdom. There are too many places treating too small numbers, so expertise is gained slowly," he said, adding that there are few full-time pediatric diabetes teams in the United Kingdom compared with the United States and Germany.

"They may only spend 3 to 8 hours per week doing it and so do not get the exposure that helps apply technology. This poorer training program plus less engagement in technology is probably the answer," Dr Hindmarsh commented.

He pointed to another study finding, that even among injection users, HbA1c levels were worse in the United Kingdom, at 9.0%, compared with 8.5% in the United States and 8.1% in Austria/Germany. "This would suggest that the whole way we deliver care is not right."

What's needed in the United Kingdom, he said, are "managed systems that hold people accountable for the care they provide. This does not happen in the devolved [National Health Service]. There are no outcome measures in diabetes that inform commissioners, for example. The solution is managed clinical networks that are charged with delivering outcomes."

Indeed, Dr Sherr said of the United Kingdom, "I don't think it's because [endocrinologists] over there don't believe in the pump. I think many times we're caught in the situation where we have to practice medicine within the confines we have."

Discrimination by Race, Gender, Age?

Dr Sherr and colleagues also found that ethnic minorities were far less likely to receive insulin pumps in all three regions, with just 22% using them compared with 34.5% of nonminority patients (odds ratio [OR], 0.54, P < .001), even after adjustment for age, diabetes duration, sex, and the specific registry.

On the other hand, girls were more likely than boys to be using pumps (OR, 1.22).

Differences by age were seen in the three regions.

In Germany/Austria, about 70% of children younger than 6 years were on pumps, compared with just 35% to 40% of older kids. In contrast, teens in the United States were more likely than younger kids to use pumps, while rates for all ages were similarly low in the United Kingdom.

Evidence shows that even young children do well with insulin pumps, Dr Sherr noted. "So what's wrong with our prescribing patterns? Do we need to rethink how we as providers designate someone as suitable for pump therapy?"

She urged clinicians to stay up-to-date with the latest technology.

"People tend to get comfortable with certain things and they may feel uncomfortable with the technology, which I think affects prescribing patterns."

As yet, there isn't much long-term cost/benefit data showing that the advantage of insulin pump and related technologies in preventing type 1 diabetes complications outweighs the cost of the devices.

However, such data could come from the T1D Exchange, a research and clinical platform created in 2009 by the Helmsley Charitable Trust, based in the United States.

"Is there benefit in terms of up-front costs? I think there probably is....The T1D Exchange should be able to get those data to provide payers," she noted.

She also pointed out another implication of her findings: "These are three developed [regions] with a lot of access to various technologies. What's happening in all the other places? Globally, I think it's all about trying to make sure our youth get the best opportunities available and seeing how we can help other areas that may be more disadvantaged."

Dr Sherr's nonprofit employer has received research funding from Medtronic with no personal compensation to her. Dr Hindmarsh has no disclosures.

Diabetologia. Published November 7, 2015. Abstract

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