Clinical Practice Factors That Define Insulin Pump Readiness

Abstract

The American Association of Clinical Endocrinologists/American College of Endocrinology and Endocrine Society guidelines on insulin pump use emphasize patient assessment to determine pump readiness for patients with type 1 diabetes (T1D). While guidelines mention the importance of the clinical practice context, such as the presence of a comprehensive pump management program and prescribing provider expertise in pump therapy, primary emphasis is placed on the measurement of patient knowledge of diabetes management, their mental and psychological status, and adherence to self-care. But how clinics define and assess “pump readiness” is not standardized, and the extent to which this process is linked to systematic differences in the allocation of healthcare technologies by race and class is unclear. In this comparative qualitative study, we describe how two ADA recognized pediatric endocrinology centers with different prevalences of patient pump use (32% vs. 77% of patients with T1D) also differ in how they determine pump readiness. In the clinic with higher overall pump use, there are no differences in frequency of pump use between non-Hispanic white and ethnic minority patients, and differences by insurance status are small. In contrast, in the clinic with lower overall pump use, there are large differences in pump use by race and insurance status. To explore these trends, we conducted over 400 hours of observations of clinical encounters and decision-making processes and fifteen 30-minute interviews with pediatric endocrinologists, nurses, certified diabetes educators, and other staff and coded the data using Atlas.ti. Findings suggest pump allocation is shaped by how: 1) providers respond to patient “cultural capital” or interaction styles, 2) clinics frame and engage with medical technologies (e.g., “pro-tech” practices such as ongoing provider and patient education to support new devices), and 3) clinics organize provider care and decision making processes (e.g., professional opinion vs. use of metrics). Disclosure C. Puckett: None. J.C. Wong: Research Support; Self; Dexcom, Inc.. Other Relationship; Self; Tidepool Project.