SES-Related Insulin Pump Uptake Disparities Seen in 2 Canadian Provinces

Investigators from Canada are calling for complete financial coverage of insulin pumps for children with type 1 diabetes (T1D) following their study results that show unequal financial coverage of the pumps and socioeconomic status (SES) disparities between the Canadian provinces of Manitoba and Québec may have contributed to pump uptake disparities.

The authors pointed out all provinces in Canada have universal pediatric coverage programs, and that although these are meant to improve access to the pumps, levels of financial coverage differ among the provinces and that may be a contributing factor to pump uptake disparities.

Their findings were published online today in JAMA Network Open, with their data analysis seeking to answer this question: Are SES disparities in insulin pump uptake in children with T1D different under the fully funded government program in Québec and the partially funded government program in Manitoba? To accomplish this, they conducted 2 parallel population-based cohort studies: from April 1, 2011, to March 31, 2017, in Québec (n = 2919; 53.1% male), and April 1, 2012, to March 31, 2017, in Manitoba (n = 636; 57.2% male). Data were analyzed between July 1, 2019, and November 30, 2021. Québec and Manitoba have the second and fifth largest populations, respectively, of all Canadian provinces.

Far fewer children in Manitoba were using an insulin pump vs children in Québec (16.7% vs 36.6%) despite the overall mean ages at diagnosis being close to equal, at 8.8 (4.4) and 8.3 (4.4) years, respectively. Age differences surfaced, however, when comparing age at T1D diagnosis between pump and nonpump users in Québec.

In Québec, age of T1D diagnosis was close to 13% younger among pediatric insulin pump users compared with those not using a pump: 7.6 (4.1) vs 8.7 (4.5) years. No age difference at diagnosis was seen in Manitoba among these same groups, nor did the majority sex distribution (male) differ among pump and nonpump users in either province.

“To our knowledge, the pump program in Ontario is the only program that has been systematically evaluated. Among Ontario children with T1D, those of lower SES were less likely to start pump therapy and more likely to discontinue it than those of higher SES,” the authors wrote. “But to our knowledge, comparisons of differing funding structures within a single country have not been performed.” They hypothesized that Québec would have fewer disparities vs Manitoba.

When level of material deprivation/SES was considered, pump uptake dropped in both provinces. In Québec, an 11% drop was seen (adjusted HR [aHR], 0.89; 95% CI, 0.85-0.93), and in Manitoba, there was a 30% drop (aHR, 0.70; 95% CI, 0.60-0.82). These results remained consistent when the investigators considered the influence of ethnicity on pump uptake.

Overall, SES-related pump uptake disparities were greater in Manitoba compared with Québec (I2, 87.7%; 95% CI, 52.5%-96.8%; P = .006; Cochran Q, 8.15), despite the provinces having similar SES profiles, and an inverse linear association was seen between pump uptake and increasing deprivation in both provinces, the authors noted:

• Québec:
  • Material deprivation index:
    • Pump users: 22.2% in quintile 1 vs 18.1% in quintile 5
    • Nonpump group: 17.0% vs 24.8%, respectively
  • Social deprivation index:
    • Pump users: 26.7% vs 11.6%
    • Nonpump group: 22.9% vs 17.2%
• Manitoba:
  • Material deprivation index:
    • Pump users: 29.2% vs 6.6%
    • Nonpump group: 12.8% vs 20.2%
  • Social deprivation index:
    • Pump users: 34.9% vs 14.2%
    • Nonpump group: 27.4% vs 16.8%

Quintile 1 is the least deprived and quintile 5, the most deprived.

An accompanying editorial highlighted that the study findings point to reasons beyond financial capability to pay as being more responsible for the pump uptake disparities (eg, parental education level, work obligations, race and ethnicity, family structure, transportation difficulties, ) vs cost alone when considering SES. It also points to possible contributions from implicit bias, which the authors were unable to control for and may have limited generalizability of their findings. Proposed solutions include expanding future studies to investigate prescribing practice biases.

“Future research should examine SES disparities in these devices across same-country jurisdictions and explore the contribution of patient and health care professional factors on disparities in diabetes technology use,” the authors concluded. “Programs aimed at reduction of educational, ethnic, and monetary disparities are essential to improve health equity, and further research into family preferences and health care professional biases are needed to optimize the care of children with T1D.”

Reference

Ladd JM, Sharma A, Rahme E, et al. Comparison of socioeconomic disparities in pump uptake among children with type 1 diabetes in 2 Canadian provinces with different payment models. JAMA Netw Open. Published online May 4, 2022. doi:10.1001/jamanetworkopen.2022.10464