Understanding Cost Considerations Around Diabetes Technology in the T1D Community

Results of a qualitative study of persons living with type 1 diabetes (T1D) and their families showed cost considerations for diabetes technology uptake extend outside of finances and include time, cost to society, morality, and interpersonal relationships.

Findings, published in Diabetic Medicine, ultimately illustrate a broad consensus on how cost is experienced by stakeholder groups, while authors noted this knowledge can help clinicians and researchers promote equitable device uptake and anticipate barriers.

Although diabetes technology is associated with improved T1D outcomes and cost is a modifiable barrier to its use, little is known about the nuances of cost considerations among this population, researchers wrote.

“With increasing government approval of algorithms that allow for automated insulin delivery as well as the increased adoption of do-it-yourself hybrid closed-loop algorithms, it is important to understand barriers in adoption of these technologies in order to facilitate equitable uptake across all persons with T1D,” they said.

Research has also shown there is a differential uptake of diabetes technology among youth from lower socioeconomic status families, while racial disparities in insulin pump use among children have persisted over the past 15 years, independent of socioeconomic status.

As clinicians often misidentify or over identify barriers to diabetes technology use, researchers set out to analyze qualitative data better understand “cost as a barrier in all of its forms as described by 4 stakeholder groups: youth, parents, adults and partners.”

Investigators analyzed all sections of the INSPIRE study (a mixed-methods evaluation of patients with T1D conducted in the United States and United Kingdom) that were previously coded and related to cost. Because the dataset with cost-related codes was anonymous, demographic data were not available for the current analysis. In the broader INSPIRE study, adults were between ages 18 and 77 while 92% were non-Hispanic White. Youth were between ages 9 and 21.

Topic themes were identified and stratified in accordance with the Social Ecological Model (SEM), “a theoretical framework which accounts for interplay between individual, relationship, community and societal factors on behavior.”

A total of 5 thematic levels of cost were identified: policy, organizational, insurance, interpersonal and individual. Responses also showed “equitable diabetes technology access was an important policy-level theme.” Additional findings included:

• The insurance-level theme had multiple subthemes which predominantly carried a negative valence
• Participants emphasized the psychosocial burden of cost by identifying diabetes costs to their families, guilt of disease-associated costs, and frustration in the time and involvement required to ensure insurance coverage
• Philosophical considerations of equity and access to diabetes technology for all persons with T1D were frequently discussed
• Participants’ prior experiences with diabetes technology shaped their perception of automated insulin delivery adoption

“We report that monetary and non-monetary cost considerations were important in automated insulin delivery uptake for all 4 stakeholder groups, spanning the individual, their family and society at large,” authors wrote.

By incorporating discussions about guilt around T1D cost, time spent with payers, and insurance-related barriers during clinical encounters, providers may help decrease the psychosocial burden of the disease.

The secondary nature of the analysis marks a limitation to the study. As participants were mostly non-Hispanic White, the potential for sampling bias exists and findings may not be generalizable.

“Cost plays a role in contributing to disease management stress and logistics as well as one's attitude and uptake of technological advances in diabetes care,” researchers concluded. Knowledge of these conditions “is one strategy to bridge disparities in automated insulin delivery uptake for persons living with T1D and their families,” they said.

Reference

Addala A, Suttiratana SC, Wong JJ, et al. Cost considerations for adoption of diabetes technology are pervasive: a qualitative study of persons living with type 1 diabetes and their families. Diabet Med. published online April 1, 2021. doi:10.1111/dme.14575