Insulin Pumps Used Less in Black Children, Even With Insurance

Miriam E. Tucker

September 10, 2020

Black children with type 1 diabetes in the United States are far less likely than white children to be prescribed insulin pumps, even among those with private health insurance, new research suggests.

The data were published online September 1 in the Journal of Pediatric Nursing by Terri H. Lipman, PhD, professor of nursing at the University of Pennsylvania School of Nursing, Philadelphia, and colleagues.

The results are from a retrospective chart review of 1212 children seen in 2005 and 1040 to 1519 children seen per year during 2011, 2013, 2015, 2017, and 2019 at the Children's Hospital of Philadelphia.

The total number of children with type 1 diabetes using insulin pumps increased overall in all groups, but racial disparities have persisted over time. Black children have been only about half as likely as white children to use insulin pumps, while Hispanic children fall in between.

The study did not examine potential causes of the disparities in treatment, but "provider bias has been shown to play a critical role in the prescribing of diabetes technologies. The provider perceptions of a family's ability to incur the costs of new therapies, and of family competence, are important factors in determining the prescribed treatment regimens," Lipman and colleagues write.

Specifically, insulin pump users and/or their caregivers must be trained to change infusion sets, fill pump cartridges, program the pump, and "demonstrate a willingness to collaborate with healthcare providers to achieve optimal diabetes therapy," the authors say.

"A key component to prescribing pump therapy has been providers' judgment regarding 'best' candidates — those who are perceived to have the understanding and commitment to master basic diabetes self-management behaviors," they add.

In order to address this "remarkable lack of progress" over the past 15 years, Lipman and colleagues advise addressing the drivers of these disparities as well as the use of "agnostic, standardized diabetes treatment protocols" with the aim of reducing "unconscious bias that influences prescribing of diabetes technology."

Persistent Disparities Since 2005

The overall rate of insulin pump use rose from 9% in 2005 to 57.6% in 2019.

In 2005, white children had double the rate of pump use compared with black children (10% vs 5%; P < 0.05), a gap that had widened by 2019 (64.9% vs 25.4%; P < .001). Among Hispanic children, for whom data were not available in 2005, pump use in 2019 was 40.8% (P = .005 for Hispanic vs black).   

The odds ratio for pump use for white versus black children was 3.2 in 2011 (P < .001) and 2.6 in 2019 (P < .001). For Hispanic children, the odds ratio compared with black children was 1.3 in both 2011 and 2019 (P = .005).

In each of the years studied, significantly more black than white children had government insurance (P < .001), although this was not always the case for black versus Hispanic children.

However, regardless of health insurance status, white children were significantly more likely than black children to be treated with insulin pumps during each of the years studied between 2011 and 2019.

Among the subgroup with commercial insurance, compared with black children pump use was twice as common among white children (P < .001) and 1.5 times more common among Hispanic children (P = .02). Those odds ratios were similar among children with government insurance.

Possible Solutions

According to Lipman and coauthors, community health workers may help reduce these disparities, as they "share the life experiences of marginalized patients and may be able to improve patient–provider communication and advocate for the patient."

They additionally note that implementation of community health worker programs using evidence-based treatment algorithms has been shown to be cost-effective in improving outcomes in high-risk vulnerable populations. 

They also recommend the Family Management Measure to assess parental perceptions of competency in managing their child's chronic condition.

Ultimately, they say, "Interventions must be developed to address these disparities so that optimal diabetes care can be provided to children of all racial, ethnic, and socioeconomic backgrounds."

Lipman and colleagues have reported no relevant financial relationships.

J Pediatr Nurs. Published online September 1, 2020. Abstract

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