Device 'Hassle' Deters Use in Some Type 1 Diabetes Patients

Miriam E Tucker

December 14, 2016

Perception of "hassle" is the most common modifiable barrier keeping people with type 1 diabetes from choosing to wear insulin pumps and continuous glucose monitors (CGMs), new research indicates.

Findings from a survey of more than 1500 participants in the T1D Exchange were published online November 29 in Diabetes Care by Molly L Tanenbaum, PhD, of the department of pediatrics, Stanford University School of Medicine, Palo Alto, California, and colleagues.

In the T1D Exchange, which includes data for more than 28,000 type 1 diabetes patients at 75 specialty clinics around the United States, about two-thirds were wearing insulin pumps, but in 2013–2014 only about 9% were using CGMs.

Cost and lack of insurance were the most often-cited reasons for not wearing insulin pumps or CGMs.

But the study's main focus was on potentially modifiable barriers for which interventions could be developed to improve uptake. Of those, "hassle" and cosmetic concerns about wearing a device on the body all the time topped the list, and these reasons were most often cited by younger patients.

It is "important for patients and providers to have open dialogue about their thoughts about devices," Dr Tanenbaum told Medscape Medical News.

And those views may shift over time, she noted.

"Since our data show quite a variety of different barriers and reasons people may have for not using devices, some of which are modifiable, those conversations may give insight into how to address barriers with patients who may be thinking about starting to use a device or who may be thinking about discontinuing."

She added, "We definitely don't want to assume that everyone should be on devices or would benefit from them, but we also don't want to assume that those who've said 'no' in the past will never be open to trying it out in the future."

The "Hassle" Factor

A total of 1503 adult T1D Exchange participants (mean age 35 years, diabetes duration 20 years, 90% white, 61% female) participated in the survey, which used the Diabetes Distress Scale, as well as questions pertaining to technology-use attitudes (general and diabetes-specific), barriers to device use, and reasons for discontinuing devices.

Overall, 38% used insulin pumps only, 32% used insulin pumps and CGMs, 25% used multiple daily injections only, and 5% used CGM with injections.

The most commonly reported barriers were cost of supplies (61%), cost of device (57%), and insurance coverage (57%).

The next four were potentially modifiable: "Hassle of wearing devices all of the time" (47%), "Do not like having diabetes devices on my body" (35%), "Do not like how diabetes devices look on my body" (26%), and "nervous that the device might not work" (20%).

Overall, those reporting more barriers to using devices were younger, had a shorter diabetes duration, higher HbA1c, higher levels of diabetes distress, and more negative attitudes about both technology in general and diabetes-specific technology (all P < .001 except P = .006 for HbA1c).

Insulin-pump use was higher among women than men (73% vs 65%, P = .003), while CGM use didn't differ.

But interestingly, despite their greater use of pumps, women overall reported more barriers to device uptake (P = .004) and more diabetes distress (P < .001) than did men.

Why Would Patients Quit Using Diabetes Devices?

Among those surveyed, there were 249 participants who had discontinued CGM use and 72 who had stopped wearing their insulin pumps.

Of those who stopped using CGMs, the most common reasons cited were cost of supplies (35%), being bothered by alarms (32%), perceiving the alarms to be inaccurate (30%), not liking wearing diabetes devices (30%), and believing the CGM took too much time and effort to use (29%).

For quitting insulin pumps, not liking wearing diabetes devices (46%) and finding them uncomfortable/painful (44%) were the most commonly endorsed reasons, followed by cost of supplies (21%) and not trusting the device (21%).

Next Steps

Study coauthor Korey K Hood, PhD, also at Stanford, told Medscape Medical News that the survey didn't delve into more precise device-related concerns and whether certain features like tubing-free pumps or smartphone app capabilities might change patients' views.

"We tried to take a brand-neutral approach and did not get into specific features of devices. It was a global survey on devices and barriers to using them," he explained, adding that the team is planning to examine these particular issues in upcoming focus groups.

But, Dr Hood noted, clinicians should attempt to gather that information.

"If they identify a global barrier like how the device feels on the body, they should follow up to see if it is specific to work, home, activities, or possibly types of clothing or situations."

And he hopes the team's research can aid clinicians in addressing these obstacles.

"Our next steps are to develop interventions that match specific barriers. These interventions will be clinic-based and can be rolled out quickly and without disrupting clinic flow. That is our goal."

This study received support from the Leona M and Harry B Helmsley Charitable Trust. The authors have no relevant financial relationships.

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Diabetes Care. Published online November 29, 2016. Abstract

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