Concerns Raised Over Inequitable Access to Freestyle Libre

Liam Davenport

April 23, 2021

Women, younger patients, and those from a White background are more likely to have access to Freestyle Libre (Abbott) glucose monitoring technology for the care of their type 1 diabetes, according to audit data from the Association of British Clinical Diabetologists (ABCD).

The data from this "large cohort...suggests that there may be inequitable access" to the technology, said Dr Emma Wilmot, University Hospitals of Derby and Burton NHS Trust, Derby.

She added that "particular concern is raised around access in men, in the elderly population, and particularly those from Asian and Black ethnic backgrounds".

Dr Wilmot noted that the JDRF’s (Juvenile Diabetes Research Foundation) recent Pathway to Choice report, which aims to improve access to type 1 diabetes technology, has "identified deprivation as a potential barrier".

While gender, age, and ethnic background were not highlighted in the JDRF report, they "definitely require further exploration", she said.

Healthcare professionals should therefore "work together to ensure more equitable access to technology".

Moreover, healthcare professionals "must ensure we are objective when considering people against criteria for funding, and we need to increase the awareness of the availability of technology in groups with lower uptake", Dr Wilmot said.

The research was presented at the Diabetes UK Professional Conference 2021 on April 22.

Concerning Reminder

"This important research... is a concerning reminder that health inequalities exist throughout diabetes care," Eddie Johnston, research communications officer at Diabetes UK, commented in a news release.

"We hope this study acts as a catalyst for further research into why these inequalities exist and how to address them, to make diabetes technologies widely accessible and easier to use.

"This is vital in ensuring everyone has equal opportunity to benefit, helpingmore people live well with diabetes."

Exponential Uptake

Dr Wilmot began her presentation by noting that there has been "a recent exponential increase in the uptake of Freestyle Libre across England", rising from 10.7% having access in April 2019 to 36% by January 2021.

This was "largely driven" by changes to the way the technology was funded by NHS England in April 2019, with it becoming universally available on prescription.

ABCD launched its audit in 2017, with the aim of "understanding the real-world outcome associated with Freestyle Libre use", Dr Wilmot said, with initial findings demonstrating a "significant reduction" in HbA1c levels, hypoglycaemia and hospital admissions, alongside "improvements in diabetes-related distress".

Women Over-represented

To assess whether there is equitable access to Freestyle Libre, the team collated anonymised data submitted by clinicians from 102 centres across England and compared them with the national type 1 diabetes population.

Using details from the audit on patients aged over 20 years for whom there was baseline data, they included 12,320 Freestyle Libre users, alongside 236,660 patients from the 2018/2019 National Diabetes Audit (NDA) for whom at least partial demographics were available.

Looking at the gender distribution, 49.5% of Freestyle Libre users were male versus 56.5% of the overall type 1 diabetes population (p<0.001).

"This would suggest a relative over-representation of females," Dr Wilmot said.

Age Differences

There were also significant differences in age distribution between users of the technology and the general type 1 diabetes population (p<0.0001).

Users "tended to be younger", Dr Wilmot said, "and when we look at the older populations, there’s lower uptake...compared with the NDA data".

The duration of diabetes was significantly longer among Freestyle Libre users than the general type 1 diabetes population (p<0.0001), with a peak initiation at over 20 years of diabetes duration.

Asian and Black Patients Underrepresented

Finally, the researchers found that users "were more likely to be White versus non-White compared with the NDA cohort", Dr Wilmot said, with lower uptake in the mixed, Asian and Black ethnic groups (p<0.001).

Specifically, 82.2% of Freestyle Libre users were White, compared with 79.6% of the overall type 1 diabetes population, while 0.6% of users were Black versus 2.7% of the overall population.

Similar figures were seen for the Asian population, where 2.9% were users of the technology versus 4.3% of the overall type 1 diabetes population. Equivalent figures for the mixed population were 0.5% and 1.1%, respectively.

Pump Uptake Also Affected

Dr Wilmot noted that there are some limitations to the study, in that the audit is relatively small, and the criteria for qualifying for Freestyle Libre have changed since the audit was launched, which "may have impacted on the sociodemographic groups that are reporting".

She added that women may have used the technology in pregnancy, "leading to an over-representation of females, and it will be interesting to see whether increased continuous glucose monitoring in pregnancy impacts on that over time".

Following her presentation, session chair Dr Amrit Lamba, clinical and managing partner at Colindale Medical Centre, London, asked whether the trends highlighted in the study are "particular to Freestyle Libre" or apply to other diabetes technologies.

Dr Wilmot said data from the NDA on pump uptake indicates that "they tend to be used [more] frequently in females, and again we need to understand whether that is all driven by pregnancy".

"We also know that, certainly for pump uptake, those from the least deprived quintiles of society are the most likely" to access them.

Objective Assessments

Dr Lamba then wondered how "we work towards equitable access".

Dr Wilmot replied that the Pathway to Choice report is a "must-read for any healthcare professional working in diabetes", adding that she was "quite shocked" to read healthcare professionals are less likely to have discussions about technology "with people from more deprived backgrounds".

She continued that previous data suggest that healthcare professionals are "fairly rubbish" at predicting which patients will do well with technology and those who will not, "so I think we all have a role to be very objective in how we assess people against the criteria for funding".

The ABCD nationwide Freestyle Libre audit is an independent audit supported by an unrestricted grant from Abbott.

Dr Wilmot declares relationships with Abbott Diabetes Care, Dexcomm, Diasend, Eli Lilly, Medtronic, Novo Nordisk and Sanofi Aventis.

No other relevant financial relationships declared.

Diabetes UK Professional Conference 2021: Abstract P211. Presented 22 April.

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