Outcomes and experiences of families with children with type 1 diabetes on insulin pumps through subsidised pump access programs in Western Australia

Type 1 Diabetes in Children and Adolescents.

Increasing numbers of children and adolescents with type 1 diabetes (T1D) have been placed on insulin pump therapy. Nevertheless, data are limited regarding patterns of pump use during the first year of treatment and the clinical and socioeconomic factors associated with early use of pump therapy. Therefore, we sought to determine factors associated with pump therapy within the first year of diagnosis in youth enrolled in the Pediatric Diabetes Consortium (PDC) T1D New-Onset (NeOn) Study. The NeOn Study includes youth <19 years old at T1D diagnosis who have been followed from the time of diagnosis at seven U.S. pediatric diabetes centers. Cox regression was used to determine factors associated with transition from injection to pump therapy during the first year of T1D in 1,012 participants. Twenty-seven percent (n=254) of participants began pump therapy within the first year of diagnosis, ranging from 18% to 59% among the seven centers. After adjusting for center effect, factors associated with pump use in multivariate analysis included private health insurance (37% vs. 7%; P<0.001), having annual household income over $100,000 (50% vs. 15%; P<0.001), and non-Hispanic white race (36% vs. 11%; P<0.001). The hemoglobin A1c level did not appear to influence the decision to initiate pump use. Participants of non-Hispanic white race and higher socioeconomic status were more likely to be placed on pumps during the first year. Further investigations are needed to gain a better understanding of barriers to use of pumps in youth with T1D, especially in disadvantaged and minority families.

Intensified insulin delivery using multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) is recommended in children with type 1 diabetes (T1D) to achieve good metabolic control. To examine the frequency of pump usage in T1D children treated in SWEET (Better control in Paediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) centers and to compare metabolic control between patients treated with CSII vs MDI. This study included 16 570 T1D children participating in the SWEET prospective, multicenter, standardized diabetes patient registry. Datasets were aggregated over the most recent year of treatment for each patient. Data were collected until March 2016. To assess the organization of pump therapy a survey was carried out. Overall, 44.4% of T1D children were treated with CSII. The proportion of patients with pump usage varied between centers and decreased with increasing age compared with children treated with MDI. In a logistic regression analysis adjusting for age, gender and diabetes duration, the use of pump was associated with both: center size [odd ratio 1.51 (1.47-1.55), P < .0001) and the diabetes-related expenditure per capita [odd ratio 1.55 (1.49-1.61), P < .0001]. Linear regression analysis, adjusted for age, gender, and diabetes duration showed that both HbA1c and daily insulin dose (U/kg/d) remained decreased in children treated with CSII compared to MDI (P < .0001). Insulin pump therapy is offered by most Sweet centers. The differences between centers affect the frequency of use of modern technology. Despite the heterogeneity of centers, T1D children achieve relatively good metabolic control, especially those treated with insulin pumps and those of younger age.

Erratum

Persistence with insulin pump therapy among children and young adults with type 1 diabetes in Germany: An update.

Insulin Pumps

The use of continuous subcutaneous insulin infusion (CSII) (i.e. insulin pump) therapy, continues to grow among patients with type 1 and type 2 diabetes increasing the likelihood that these patients will be encountered in the hospital setting. Prior to the development of protocols, guidelines and order sets that standardize the inpatient management of this group of patients, the decision to continue CSII during an inpatient admission was often arbitrary. While many patients wish to continue pump therapy when admitted to the hospital, lack of familiarity with these devices led to therapeutic misadventures, such as abrupt discontinuation of CSII without transition to scheduled subcutaneous (SC) insulin increasing the risk for both hypoglycemia and hyperglycemia. This review provides information regarding the basics of CSII therapy and summarizes the literature describing the current practice standards and recommendations that have been published as a way of guiding the safe use of these devices in the inpatient setting. Proper assessment of patients who are able to safely manage their pump during admission is critical. The availability of hospital personnel who are knowledgeable in CSII therapy allows for ongoing assessment of the continued safety of CSII use and can guide transition to scheduled SC insulin therapy when patients are no longer capable of self-management. For patients who are unable to self-manage their pump therapy in the hospital, guidelines for transition to conventional subcutaneous insulin therapy is provided. We conclude that these devices can be safely used in the hospital provided that there is a standardized approach to patient selection and that there is a process for assessing glycemic control throughout the hospital stay.

&lt;sec&gt;&lt;st&gt;Introduction&lt;/st&gt; Initiation of insulin pump therapy in children with type 1 diabetes results in better glycaemic control, reduction in the short-term and long term complications and in better quality of life. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Objectives&lt;/st&gt; To determine the impact of insulin pump on glycaemic control (HbA1c), BMI and occurrence of severe complications in children with IDDM in a secondary care centre. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Methods&lt;/st&gt; A retrospective study of children with type 1 diabetes on insulin pump therapy for at least one year at the time of the study was conducted. HbA1c, BMI and frequency of severe complications one year before and after introduction of insulin pump were compared. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Results&lt;/st&gt; Twelve out of the thirty children (40%) on insulin pump therapy met our inclusion criteria. Their mean age at the time of the study was 12.6 years. Seven boys (58.3%) and five (42%) girls were studied. The mean duration of diabetes was 5.5 (±2.2) years. The mean HbA1c before the introduction of pump therapy was 8.1% vs. 7.1% one year after; while the mean BMI z-score was 0.79 before and 0.88 after. Severe hypoglycaemia and DKA were noted in two children before but none after the initiation of pump therapy. The mean HbA1c decreased by 0.4% at 3 months (p 0.05) and by 1% at 2 months (p 0.013) of pump therapy. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Conclusions&lt;/st&gt; Initiation of insulin pump therapy results in significant reduction in the HbA1c within the first twelve months of therapy with a decrease in the frequency of occurrence of severe complications. &lt;/sec&gt;

Predictors of glycemic control on insulin pump therapy in children and adolescents with type I diabetes

Introduction The advanced bolus options improve glycemic control of patients with type 1 diabetes (T1D) on insulin pump (IP) therapy. This is extremely important for the patients who do not use CGM (continuous glucose monitoring) regularly. Objective To compare the difference in the parameters of glycemic control (HbA1c, postprandial increase of blood glucose and number of hypoglycemic episodes per week) between the group of patients who use bolus calculator for <50% of the total daily boluses and the group the patients who use bolus calculator for ≥50% of total daily boluses. Patients and methods The study included 41 patients aged over 18 years with T1D on IP therapy in Republika of Srpska. All patients used IP for at least one year prior to participation in the study. Before the IP therapy was initiated, all the patients were trained for carbohydrate counting in course of flexible insulin therapy training (FIT). Professional software, CareLink Pro® Software (Medtronic Inc., Northridge, CA, USA) was used to download data from insulin pumps to a personal computer. The default frequency of bolus calculator use was ≥50% of total daily boluses. Results No statistically significant difference was found in HbA1c (6.61 ± 1.10 vs. 6.77 ± 0.97, p = 0.624) or the number of hypoglycemic episodes (2.00 (1.00, 4.00) (1.0–6.0) versus 3.00 (2.00, 3.50) (1.0–5.0), p = 0.322) between the group of patients who have used bolus calculator for <50% of the total daily boluses and the group of patients who used bolus calculator for ≥50% of total daily boluses. Patients who have used bolus calculator had significantly lower postprandial increase in blood glucose after breakfast. Conclusion Among the patients with T1D on IP therapy, who do not regularly use CGM the use of the bolus calculator and use of different types of boluses, can improve glycemic control on IP therapy.

Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy can be Safely Used in the Hospital in Select Patients

To determine the impact of insulin pump therapy (continuous subcutaneous insulin infusion) on key parameters of diabetes management including quality of life in children and adolescents with Type 1 diabetes mellitus (T1DM). All patients started on insulin pump therapy were prospectively followed before and after institution of insulin pump therapy. Data collected included age, duration of diabetes, glycated haemoglobin levels (HbA1c), anthropometric data and episodes of severe hypoglycaemia defined as hypoglycaemia resulting in coma or convulsion. A subset of patients also completed the Diabetes Quality of Life Instrument (DQOL) and Self-Efficacy for Diabetes Scale (SED) questionnaires to assess quality of life. At the time of analysis, 100 patients had been managed with insulin pump therapy. The mean age when starting pump therapy was 12.5 (3.9-19.6) years. Duration of therapy ranged from 0.2 to 4.0 years (mean 1.4 years, median 1.5 years). HbA1c decreased from 8.3 +/- 0.1% prior to pump therapy to 7.8 +/- 0.1% (P < 0.0001). Episodes of severe hypoglycaemia decreased from 32.9 to 11.4 per 100 patient years. Components of quality of life measures showed improvement on pump treatment. BMI standard deviation scores (z scores) did not increase. Pump therapy is proving an effective means of insulin therapy in the young patient that shows promise to improve glycaemic control with a reduction in hypoglycaemia frequency. Quality of Life measures suggest that psychosocial outcomes may be improved.

Objectives: The healthcare utilization benefits associated with insulin pump therapy compared to multiple daily injections (MDI) therapy are not well known. This study sought to compare the impact of using a durable insulin pump versus MDI therapy on healthcare utilization and A1C among individuals with type 1 diabetes (T1D). Methods: This population-based, longitudinal analysis used a large repository of healthcare claims data to compare diabetes-related and all-cause inpatient admissions (IP) and emergency room (ER) visits in individuals with T1D using durable pumps (N=1,286) versus MDI (N=3,854). The study period was June 1, 2017 to July 31, 2019. The study index date was assigned to the first date of pump use in the pump cohort and a random index date was assigned to the MDI cohort. Continuous insurance enrollment 1-year before and 1-year after adoption/index date was required. Generalized linear model regression was used to test the difference-in-difference effect of therapy type on rates of utilization and A1C. The U.S. Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicator (PQI) algorithm was used to define diabetes-related utilization. Results: Individuals on insulin pump therapy had a significant decrease in IP utilization compared to little change among individuals using MDI therapy (-41% vs. +3%, p=0.01), and similar decreases in ER utilization (-27% vs. -16%, p=0.64). Combining diabetes-related IP and ER utilization, individuals on insulin pump therapy experienced a decrease of 34% compared to decrease of 8% among those using MDI therapy (p= 0.02). Individuals on insulin pump therapy also experienced a larger decrease in A1C (-7% vs. -1%, p=&amp;lt;0.0001). Conclusions: Compared to MDI therapy, use of a durable insulin pump associated with a significantly smaller increase in diabetes-related healthcare utilization and A1C over time. Disclosure M. Shah: Employee; Self; Medtronic. C. Zhu: Employee; Self; Medtronic. K. Wherry: Employee; Self; Medtronic.

Insulin pump therapy is a current treatment option for children and adolescents with type 1 diabetes. Insulin pumps can provide a greater flexibility in insulin administration and meal planning, as...

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