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In Canada, poor children with type 1 diabetes less likely to receive an insulin pump

10/05 - Canadian children with type 1 diabetes who are poor are less likely to receive an insulin pump, especially where the cost is only partially funded, a new study finds.

The analysis of data from more than 3,500 children with type 1 diabetes from two Canadian provinces - one with full and the other only partial coverage for pumps - revealed that materially disadvantaged children were less likely to receive a pump in both provinces. But the disparity was significantly greater in Manitoba, where pumps were only partially funded, as compared with Quebec, where they are fully covered, according to the results in JAMA Network Open.

"The take-home message from our study is that healthcare systems providing full financial coverage for diabetes devices and supplies can reduce, but not completely eliminate, socioeconomic disparities in uptake of these devices in children with type 1 diabetes," said the study's first author, Dr. Jennifer Ladd, a pediatric endocrinologist at the Montreal Children's Hospital, a clinical assistant professor at McGill University, and a Master's candidate in the Epidemiology program at McGill.

"This study will now serve as important evidence to advocate for additional funding for pump supplies for children in the province of Manitoba to reduce the disparities in pump uptake," she said.

"Importantly, the material deprivation index covers more than just financial status - it takes into account education level, and employment status," Dr. Ladd said in an email. "Other jurisdictions have found that lower parental education has been associated with lower pump uptake. We hypothesize that other factors that are not necessarily captured by these deprivation indices such as work obligations, transportation issues may play roles."

"To this end, further research to explore other critical and modifiable factors that may influence diabetes device uptake, such as patient/family preferences and healthcare professional implicit biases, is needed to truly improve equity for children with type 1 diabetes," Dr. Ladd said.

To take a closer look at insulin pump uptake in children with type 1 diabetes, Dr. Ladd and her colleagues conducted parallel, population-based, retrospective cohort studies of children from Quebec and Manitoba using multiple, linked, deidentified health administrative databases and a clinical registry.

The pump program in Quebec was initiated in 2011 and covers all pump-related costs, while the Manitoba program, initiated in 2012, pays only a portion of the needed supplies with an income-based deductible before government coverage.

The researchers focused on 2,919 children in Quebec with type 1 diabetes and an average age of 8.3 at diagnosis, and 636 children in Manitoba with an average age of 8.8 at diagnosis. Among the Quebec children, 1,067 (36.6%) were using a pump, as compared with 106 (16.7%) in Manitoba.

Dr. Ladd and her colleagues found that increasing material deprivation was associated with decreased pump uptake in both Quebec (adjusted hazard ratio 0.89) and Manitoba (aHR 0.70). When the researchers accounted for ethnic concentration, the association did not change. They also found that socioeconomic disparities in pump uptake were greater in Manitoba than Quebec.

"This study is an important contribution to the literature on the impact of social determinants of health on diabetes technology use," said Dr. Risa Wolf, an assistant professor of pediatrics at the Johns Hopkins University School of Medicine in Baltimore, and a pediatric endocrinologist at the Johns Hopkins Children's Center.

"Despite the recognized benefits of insulin pump use on glycemic control and quality of life, the majority of children with type 1 diabetes in this study were not using an insulin pump," Dr. Wolf said in an email. "Insulin pump use was higher in Quebec with universal pump coverage compared to Manitoba with partial pump coverage."

"Even in the setting of universal and partial pump coverage, and controlling for other potentially contributing factors (region of residence and ethnic concentration), material deprivation was still associated with lower insulin pump use," Dr. Wolf said. "This study highlights the need for continued efforts to overcome barriers to diabetes technology use and increase access to technologies that can improve quality of life and long-term outcomes. Universal pump coverage could help improve access by reducing costs to families, particularly those with material deprivation, but as the authors suggest, minimizing the criteria for being able to start on a pump may also help mitigate these disparities."

The new study spotlights SES disparities in insulin pump use in children, said Dr. Meredith Wilkes, an assistant professor of pediatrics in the division of pediatric endocrinology and diabetes and medical director of the pediatric diabetes program at the Icahn School of Medicine at Mount Sinai in New York.

"Diabetes technology including insulin pump therapy has the potential to improve glycemic control in children and adolescents as well as reduce risks of acute and chronic complications due to hyperglycemia," Dr. Wilkes said in an email. "Improved coverage for pumps and related supplies may partially reduce barriers for some families; however further research into the etiology of these disparities is needed as well as programs to promote health equality."

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