Socioeconomic status influencing the cessation of insulin pump therapy in children with type 1 diabetes mellitus: A cohort study

INTRODUCTION

Diabetes mellitus (DM) is a common chronic condition in the pediatric population. In 2019, it was estimated that there were 36,000 individuals under 19 living with diabetes in the United Kingdom;^[1] 90% of this age group had a diagnosis of type 1 diabetes mellitus (T1DM).^[1]

Technology is being developed in an attempt to improve the quality of life (QoL) and blood glucose (BG) control. Insulin pump therapy (also known as continuous subcutaneous infusion of insulin, CSII)^[2] is continually advancing,^[3] aiming to streamline management for patients. However, there are many factors to consider before commencing insulin pump therapy. There have been many campaigns to encourage the use of insulin pumps, with a directive at the time of this study encouraging all Health Boards in Scotland to commence at least a quarter of children with T1DM on insulin pumps.^[2]

There are several advantages associated with the use of insulin pumps. Smaller doses of insulin can be administered compared to injections^[2] which is useful in younger/newly diagnosed patients.^[4] Basal insulin can be adjusted to vary depending on the time of day, allowing higher insulin ratios to be administered at times when the patient is at higher risk of hyperglycemia.^[2,3] There is a perceived greater flexibility with the insulin pump, allowing patients to be less rigid about their mealtimes.^[2,5] Insulin pumps are also considered to be more helpful in the management of hypoglycemia as there can be an instant reduction of insulin administered.^[2] However, there are also some disadvantages to insulin pumps. The pump has to be constantly worn which can create issues with body image.^[2]

Insulin pumps only use rapid-acting analog insulin.^[2] As this insulin is given in small bursts, there is no insulin reserve within the body if there is a malfunction, unlike with injections.^[2] Therefore, the pump poses a higher risk of diabetic ketoacidosis (DKA) than injections.^[2] This has been shown in a number of studies suggesting pump malfunction to be a common cause of DKA^[6-8] and for DKA to be more prevalent in patients using pump therapy.^[5,7,9] The introduction of hybrid closed loop systems can also help improve overall BG control by more accurately and frequently administering insulin.^[10]

Insulin pumps are not suitable for all patients, and discontinuation of pump therapy should be considered if this is the patient’s preference. Cannula sites can become infected;^[8] there can be issues with compliance and severe adverse events (such as DKA)^[8] or no improvement in BG control (i.e., continued high hemoglobin A1c [HbA1c] values).^[11] It is worth noting that pump cessation is uncommon and is associated with higher HbA1c values.^[12]

The Silesian University of Technology conducted a study whereby children completed questionnaires investigating reasons for insulin pump cessation. Patients reported a greater sense of disease burden with insulin pumps—this was the most common reason for cessation.^[13] Another study has identified socioeconomic status as a factor in T1DM management, showing that more patients from deprived areas are discontinuing insulin pump therapy.^[14] Older age was shown to be less associated with pump cessation.^[14]

The purpose of this study was to identify factors leading to cessation of insulin pump therapy in our center, including socioeconomic status.

MATERIALS AND METHODS

Data were collected from the electronic clinical records for those patients who discontinued insulin pump therapy. The variables noted for each of these patients stopping insulin pump therapy from January 2015 to December 2020 were as follows:

• Sex

• Age at diagnosis

• Age at time of starting pump therapy

• Age at time of stopping insulin pump therapy

• HbA1c before and after insulin pump therapy was removed

• Reasons for insulin pump removal

• Scottish Index of Multiple Deprivation (SIMD) overall quintile score.^[15]

The SIMD score, using the patient’s address/postcode, measures the affluence of particular areas, using factors such as income, education, and health.^[15] A value of 1 indicates the most deprived area, and a value of 5 indicates the least deprived.

The reasons for stopping insulin pump therapy were noted for each patient and categorized into the following groups:

• Poor BG control

• Patient preference

• Both BG control and patient preference, or other individual factors (e.g., skin problems).

SIMD data were also collected for patients who remained on insulin pump therapy (251) for the same period using electronic clinical records.

Statistical analysis was carried out using the program IBM Statistical Package for the Social Sciences Statistics 27 and analysis of variance.

RESULTS

Seventy-two patients were identified as having stopped insulin pump therapy. One patient was excluded as the child was on an insulin pump for the management of transient neonatal diabetes. 11 were excluded as there was not enough information available in the notes to collect the relevant data. Data on a total of 60 patients who stopped insulin pump therapy were thus collected and analyzed.

The median and range ages are shown in Table 1. The male-to-female ratio of patients was also recorded.

According to patient notes, most patients stopped insulin pump therapy due to poor BG control or patient preference. In some patients, it was a combination of these factors that influenced their management decision. The number of patients that stopped pump therapy for these reasons was noted, and the male-to-female ratio calculated for each. This is shown in Table 2.

SIMD quintile scores were used as a measure of socioeconomic status in this patient group. The trend for SIMD quintile scores in patients currently on insulin pump therapy from 2015 is shown in the first graph in Figure 1. There is no statistically significant difference in SIMD values for those continuing on insulin pump therapy.

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Figure 1:

(a) The first graph displays the SIMD quintile scores for all patients currently on insulin pump therapy for the management of type 1 diabetes mellitus, compared to (b) the graph showing the SIMD quintile scores for all patients stopping insulin pump therapy.

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Of the total 323 patients who were noted to have started insulin pump therapy between 2015 and 2020, 22.29% of patients discontinued pump therapy. The second graph in Figure 2 shows the trend in SIMD values for those discontinuing pump therapies. Thirty-five patients (58.3%) who stopped pump therapy were from an area with a SIMD insulin pump therapy in children with T1DM: A cohort study quintile of 1or 2, whereas 14 (23.3%) were from an area with a SIMD quintile of 4 or 5.

DISCUSSION

Our data show that there are higher numbers of patients from an area with a lower SIMD quintile score stopping insulin pump therapy than from an area with a higher SIMD quintile score. There is little difference in SIMD values for patients starting insulin pump therapy in comparison to the SIMD values for those patients who discontinued pump therapy. This suggests that socioeconomic status may be a factor in the management of T1DM, with deprivation a potential correlating factor in insulin pump cessation.

There are a number of factors influencing pump cessation. Lower socioeconomic status has been linked to higher levels of mortality in T1DM^[16] with affluence being linked to healthier HbA1c values.^[17] Poor BG control is the most common reason for pump therapy cessation; therefore, it is not surprising that socioeconomic status is an important factor in the management of T1DM.

Patients from less affluent areas may have reduced access to technology such as smartphones or even the Internet; some continuous glucose monitoring systems work optimally and solely with access to a smartphone.^[18] The National Paediatric Diabetes Audit in 2021 showed an increasing gap for insulin pump use in 2019–2020 in comparison to 2014– 2015 between the most and least deprived areas.^[19] Poorer education and language barriers may be a factor in deprived areas,^[18] contributing to poorer understanding of health and their illness, as well as the challenges that technology presents. Those families requiring interpreter services have poorer diabetes control, although there is likely to be a number of factors, including deprivation.^[20] Research has shown that there is often a reluctance for staff members in schools to be responsible for insulin administration and monitoring.^[21] Patients from deprived areas are likely to require more support to help with insulin pump therapy, and efforts should be made to address the issues where possible, before stopping insulin pump therapy. There are limitations within this study; for example, it is crucial to address that individuals living in a more deprived area may not necessarily be experiencing levels of deprivation themselves due to factors such as family income. However, SIMD is a useful measure of relative deprivation and so likely to be a good indication of socioeconomic status overall.

It is essential to consider that there may be an element of bias from healthcare professionals toward patients from more deprived backgrounds,^[18] as there is potential for clinicians to create assumptions regarding patient’s ability to insulin pump therapy in children with T1DM: A cohort study manage pump therapy.^[18] However, one objective factor is the increased HbA1c, as it poses a significantly increased risk of DKA. As discussed above, there are other factors to consider, and it is crucial to use individualized approaches to diabetic management to optimize glycemic control.

CONCLUSION

Most patients stopped using insulin pumps as a management strategy for T1DM due to poor BG control. More patients who stopped insulin pump therapy were from deprived areas than affluent areas. The cause of this is unclear and likely multifactorial.