Although universal coverage of continuous glucose monitoring (CGM) devices in 2021 led to improved care for children with diabetes in British Columbia, equity gaps for those most in need persist, a new analysis has shown .
Despite an increase in CGM uptake across all levels of deprivation a year after the introduction of universal CGM funding, an equity gap persists between the least and most deprived groups, researchers found.
“Nonfinancial burdens (need) to be addressed, such as raising awareness of diabetes technology, provider bias, and ensuring clinicians have access to appropriate training and resources,” lead author Shazhan Amed, MD, chief of the Department of Endocrinology and Diabetes at BC Children’s Hospital. in Vancouver, British Columbia, Canada, said Medscape Medical News.
Surprisingly, she said, even though overall adoption of the CGM a year after the implementation of the universal financing policy was only 50%, “today, three years after the policy, we know that CGM adoption is much higher. This (finding) highlights that it takes time for policies to take root in a population, and that systems to support technology adoption are essential, including a streamlined process for administrative approvals, as well as opportunities education for patients and their families.
At the same time, she added: “It is our role as clinicians to bring diabetes technology to all children and families living with diabetes, regardless of their background, race, education and their socio-economic status. »
The study was published online November 26 in Diabetes technology and therapeutics.
Adoption has improved, gaps remain
Researchers assessed A1c, waiting time (TIR) and pump utilization to assess the effect of a universal funding policy for CGM based on levels of deprivation in children with of type 1 diabetes (T1D) in British Columbia.
Using the BC Pediatric Diabetes Registry, they studied 477 patients with T1D and at least one outpatient visit after June 10, 2020 (i.e., 1 year before universal CGM funding took effect ). Forty-two percent of participants were women. The median age at diagnosis was 6.6 years, and the median age at study entry was 13.2 years. About 62% of participants were white and about 17% were Asian.
Postal codes were used to determine participants’ level of deprivation, according to the Canadian Index of Multiple Deprivation (CIMD). The index has four dimensions: economic dependence, residential instability, ethnocultural composition and situational vulnerability. Five quintiles were developed (quintile 1 = least disadvantaged, quintile 5 = most disadvantaged), and demographics were similar between quintiles.
Patients had an average of five visits throughout the study period. The largest proportion of patients in the dimensions of economic instability and situational vulnerability (31.9% and 34.8% of patients, respectively) belonged to the least deprived quintile (quintile 1). For the residential instability dimension, the intermediate quintiles (second, third and fourth) represented the largest proportion of patients.
No differences were observed between the five deprivation levels for HbA1c and TIR. However, for the residential instability dimension, patients with the highest level of deprivation had a lower probability of using a pump (−18.9% for quintile 5 compared to quintile 1).
CGM uptake increased across all levels of deprivation one year after the introduction of universal CGM funding. For example, the difference in sensor usage rates between the most and least disadvantaged groups was −21.0% at the time of universal coverage, and this difference narrowed to −4.6% after 12 months of coverage.
However, in the economic dependence dimension, an equity gap in CGM use persisted between the most disadvantaged and the most disadvantaged groups (−21.9 for the 5 versus 1 quintile).
Although the authors were concerned about the high rates of diabetic ketoacidosis and severe hypoglycemia episodes seen in poorer groups due to their economic dependence and situational vulnerability, they noted that overall rates were low and that these results should be interpreted with caution.
This study had several limitations. First, quintiles of the deprivation index were subject to misclassification bias. Second, the dataset comes exclusively from patients accessing care at BC’s only tertiary care children’s hospital and may not be generalizable to children accessing care in other settings. Third, the application process and waiting period may have affected CGM adoption in the first year after funding.
“Now is the time to develop multi-pronged strategies to ensure that the latest diabetes technologies are in the hands of all children and youth living with diabetes,” the authors write. “Our study adds to growing evidence that public coverage of diabetes technology is a key part of these strategies and is essential for moving the needle toward equity and justice in diabetes care.”
Language barriers
Commenting on the results of Medscape Medical NewsAlexandra Ahmet, MD, associate professor of pediatrics at the University of Ottawa and division head of the department of endocrinology at CHEO, Ottawa, Ontario, Canada, said the cost of other technologies required for optimal use of sensors and pumps could be at least partly responsible for the equity gap. “Smartphones or computers are required for most CGM and pump systems to maximize their value, including communicating blood glucose data with diabetes clinics. Patients and their families have expressed that non-diabetes technologies can be a barrier.
Although the CIMD dimension describing ethnocultural composition was not used due to the relatively homogeneous ethnic distribution in British Columbia, another challenge to diabetes technology adoption could be the language barrier, Ahmet said. “Without access to diabetes educators who speak the same languages as our patients, diabetes education, especially complex technology-related education, can be a challenge…for patients and their families.” More resources are needed to support the education of patients and families who do not speak English or French.
Additionally, visiting diabetes clinics can be difficult for some families. “Loss of income due to lack of time and lack of transportation are two potential obstacles,” she said. The same goes for education on diabetes technology, which can require time and travel.
On the positive side, she continued, the lack of between-group differences in metabolic control, as measured by HbA1c and TIR, “is different from previous studies and suggests that universal access contributes to reduce disparities.
“In Ontario, we do not have universal access to diabetes-related technologies,” she noted. “There are significant restrictions on access to the Dexcom device, which was studied in this article, and there is a gap greater than $1,000 between the cost of the diabetes pump and pump supplies and the cost provided by our government.
“I hope this study will help address the need for more universal coverage,” Ahmet concluded.
This study and the BC Pediatric Diabetes Registry are supported through philanthropic funding from the BC Children’s Hospital Foundation. Amed holds a research salary award from the BC Children’s Hospital Research Institute and has served on advisory boards for Dexcom, Abbott, Novo Nordisk, Eli Lilly and Company, Sanofi and Insulet. Ahmet served on a Dexcom advisory board.
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was editor-in-chief) and Reuters Health.