Equity Gaps in T1D Technology Persist in BC, Despite Funding

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 the most deprived persist, a new analysis showed.

Despite an increase in CGM uptake across all levels of deprivation 1 year after universal CGM funding was introduced, an equity gap remained 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 the proper training and resources,” principal author Shazhan Amed, MD, head of Endocrinology and Diabetes at BC Children’s Hospital in Vancouver, British Columbia, Canada, told Medscape Medical News.

Surprisingly, she said, although overall uptake of CGM 1 year after implementation of the universal funding policy was only 50%, “today, 3 years post policy, we know CGM adoption is much higher. This [finding] emphasizes that it takes time for policies to take hold in a population, and systems to support technology adoption are critical, including a streamlined process for administrative approvals, as well as opportunities for education for patients and families.”

At the same time, she added, “It is our role as clinicians to offer diabetes technology to all children and families living with diabetes, regardless of their background, race, education, and socioeconomic status.”

The study was published online on November 26 in Diabetes Technology & Therapeutics.

Uptake Improved, Gaps Remained

The researchers assessed A1c, time in range (TIR), and pump use to evaluate the effect of a universal funding policy for CGM across levels of deprivation in children with 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 (ie, 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 start was 13.2 years. About 62% of participants were White, and about 17% were Asian.

Postal codes were used to determine the participants’ level of deprivation, according to the Canadian Index of Multiple Deprivation (CIMD). The index has four dimensions: Economic dependency, residential instability, ethnocultural composition, and situational vulnerability. Five quintiles were developed (quintile 1 = least deprived, quintile 5 = most deprived), and demographics were similar across quintiles.

Patients had a median of five visits throughout the study period. The largest proportion of patients in the economic instability and situational vulnerability dimensions (31.9% and 34.8% of patients, respectively) were in the least deprived quintile (quintile 1). For the residential instability dimension, the middle quintiles (second, third, and fourth) accounted for the greatest proportion of patients.

No differences were observed among the five levels of deprivation for A1c and TIR. For the residential instability dimension, however, patients with the highest level of deprivation had a lower probability of pump use (−18.9% for quintile 5 vs quintile 1).

CGM uptake increased across all levels of deprivation 1 year after the introduction of universal CGM funding. For example, the difference in the rate of sensor use between the most and least deprived groups was −21.0% at the time of universal coverage, and this difference shrank to −4.6% after 12 months of coverage.

In the economic dependency dimension, however, an equity gap in CGM use persisted between the least and most deprived groups (−21.9 for quintile 5 vs 1).

Although the authors were concerned about the high rates of diabetic ketoacidosis and episodes of severe hypoglycemia that were found in the most deprived groups for economic dependency and situational vulnerability, they noted that overall rates were low, and those results should be interpreted cautiously.

This study had several limitations. First, the deprivation index quintiles were subject to potential misclassification biases. Second, the dataset was derived exclusively from patients accessing care at the only tertiary care children’s hospital in British Columbia and may not be generalizable to children accessing care in other settings. Third, the application process and waiting period may have affected CGM uptake in the first year after funding.

“The time is now to develop multipronged strategies so that the latest diabetes technologies are in the hands of all children and youth living with diabetes,” the authors wrote. “Our study adds to the growing evidence that public coverage of diabetes technology is a key component of these strategies and is essential in moving the needle toward equity and justice in diabetes care.”

Language Barriers

Commenting on the findings for Medscape Medical News, Alexandra Ahmet, MD, associate professor of pediatrics at the University of Ottawa and Division Chief for the Endocrinology Department at CHEO, Ottawa, Ontario, Canada, said that the cost of other technology required for optimal sensor and pump use may be at least partly responsible for the equity gap. “Smartphones or computers are required for most CGM and pump systems to optimize their value, including for communication of blood glucose data with diabetes clinics. Patients and families have expressed that nondiabetes-related technologies can be a barrier.”

Although the CIMD dimension depicting ethnocultural composition was not used because of the relatively homogeneous ethnic distribution in British Columbia, another challenge to diabetes technology uptake may be language barriers, said Ahmet. “Without access to diabetes educators who speak the same languages as our patients, diabetes-related education, especially complex education related to technology, can be a challenge…for patients and families. More resources are needed to support education for patients and families who do not speak English or French.”

Furthermore, visiting diabetes clinics can be difficult for some families. “Lost income because of the time and lack of transportation are two potential barriers,” she said. The same is true for education around diabetes-related technology, which may require time and travel.

On the positive side, she continued, the lack of between-group differences in metabolic control, as measured by A1c and TIR, “is different than previous studies and suggests that universal access is helping to close 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 paper, and there is a greater than $1000 gap between the cost of the diabetes pump and pump supplies and the cost that is provided by our government.

“I hope that this study will help to support the need for more universal coverage,” Ahmet concluded.

This study and the BC Pediatric Diabetes Registry are funded through philanthropic funding from the BC Children’s Hospital Foundation. Amed holds a BC Children’s Hospital Research Institute Research Salary award and has participated on advisory boards for Dexcom, Abbott, Novo Nordisk, Eli Lilly and Company, Sanofi, and Insulet. Ahmet sat on an advisory board for Dexcom.

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 a contributing editor), and Reuters Health.