Case Series Highlights Lack of Equity in T1D Care

That youths living with type 1 diabetes (T1D) who have public insurance coverage tend to have worse glycemic control due to lower rates of diabetes technology use—in the form of continuous glucose monitoring (CGM), insulin pumps, and automated insulin delivery (AID)—underscores the need to reduce roadblocks to equitable care, according to a case series report in Case Reports in Endocrinology.

In particular, there is a great need for interventions and policies that promote access to the resources these individuals with T1D need to effectively control disease.

“Our study focuses on public insurance coverage by California Children’s Services (CCS), a Medicaid supplement for children in California with certain chronic health conditions, including diabetes,” the authors explained. “Youth with CCS need to demonstrate 4 or more self-monitored blood glucose (SMBG) checks daily for a month for CGM approval, a requirement that does not exist for privately insured youth.”

Their study had 2 primary goals: to describe outcomes following participation in the CGM Time in Range Program (TIPs) and to promote the importance of CGM coverage by public insurers. Pediatric endocrinologists and clinical diabetes care and education specialists (CDCES) identified the 6 participants, all of whom were already enrolled in the CGM TIPs clinical research program, “which supports youth with T1D and public insurance to initiate and sustain CGM use,” the authors wrote.

Hemoglobin A_1C (A1C) was monitored quarterly, and the CDCES reviewed CGM data on a monthly basis, providing diabetes education and dose adjustments as needed.

The first case was a 14-year-old male patient, whose A1C fell from 12.1% to 7.1%. The CGM TIPs program provided him with a continuous glucose monitor, which he preferred to finger stick measures, and the data allayed his mother’s worries about potential hypoglycemia—a condition she attempted to head off by keeping his bedtime glucose above 200 mg/dL without prior checks. He had a 4-year history of T1D, and a principal barrier to effective diabetes management was his family’s lack of understanding of the disease.

Case 2 focused on a 20-year-old female, with an A1C that dropped to 7.1% from between 9.3% and 14.0%. As with the youth in the first case, she did not like to self-monitor her blood glucose. She had a 5-year history of T1D and Hashimoto thyroiditis, as well as a lack of parental support for her diabetes care, but has been able to self-treat successfully with long-acting insulin. Participation facilitated greater care engagement, “but as she transitions off CCS insurance after 21 years of age, continuing CGM coverage will likely be challenging,” the authors wrote.

The third case was an 18-year-old female whose A1C dropped from above 14.0% to 6.3%, whose consistent diabetes care was hindered by lack of access to nursing support and having to deal with insurance coverage issues and medical equipment supplies on her own. Participation enabled her to have consistent access to supplies, following a malfunction of her continuous glucose monitor. She had a 4-year history of T1D.

In the fourth case, which was a 17-year-old female, A1C fell from a range of 12.0%-13.0% to 7.7%. Improper T1D management was attributed to disordered eating; lack of familial support and supervision, leaving her to self-manage her T1D alone; and inconsistent supply access while using a continuous glucose monitor plus AID. She received health care navigation assistance for device malfunctions and consistent supply access, which facilitated consistent use of her AID system. She had a 9-year history of T1D.

Case 5 involved a 15-year-old male who started with an A1C above 14.0% that improved to 11.5%. Suboptimal T1D management was due to co-occurring anxiety and depression, limited health literacy, and lack of stable housing. Participation provided him with CGM and an AID system, which increased the frequency of his T1D monitoring and care self-engagement. Steady contact was also initiated, and continues, between his family and the care team. He had a 5-year history of T1D, in addition to asthma, eosinophilic esophagitis, and celiac disease, and 9 intensive care unit (ICU) admissions for diabetic ketoacidosis (DKA) over the previous 2 years.

The final case was of a 14-year-old male whose A1C improved to 8.3% from a range of 9.7% to 12.0%. Similar to the male in case 5, he had several ICU admissions for DKA within the previous year; hindrances to proper care of his diabetes included a dislike of and discomfort from the CGM sensors and an inability to meet CCS’s 4 daily SMBG checks. Program participation greatly enhanced his treatment adherence, and he initiated consistent CGM sensor use through supply and supplier communication assistance. He had a 5-year history of T1D and attention deficit hyperactivity disorder.

The study authors highlighted each of these cases demonstrates how reducing barriers to CGM access and use, as well as providing communication and supply support, can optimize T1D treatment, particularly for individuals on public insurance. In addition, they stressed there is a great need for policy change toward coverage of CGM for young persons with diabetes.

“These cases highlight the potential for combining diabetes technology and asynchronous remote monitoring to support continued use and provide education to improve glycemic control for youth with T1D on public insurance and the need to reduce barriers for obtaining CGM coverage by public insurance,” the authors concluded. “Unrestricted CGM coverage for youths with T1D on public insurance improves engagement and provides a gateway to obtaining AID systems to improve their diabetes management.

Reference

Lee MY, Tanenbaum ML, Maahs DM, Prahalad P. Overcoming barriers to diabetes technology in youth with type 1 diabetes and public insurance: cases and call to action. Case Rep Endocrinol. Published online March 1, 2022. doi:10.1155/2022/9911736