Exploring the Barriers to Uptake of Automated Insulin Delivery

Advances in technology to manage diabetes offer opportunities for precision in insulin delivery that were unimaginable a generation ago. But barriers to automated insulin delivery (AID) remain, according to authors of a recent review article appearing in Medical Devices: Evidence and Research.

Although some patients with type 2 diabetes (T2D) use insulin, those with type 1 diabetes (T1D) cannot survive without it. Those with T1D choose either multiple daily injections or delivery through a pump; which route patients choose and why is a highly personal choice, and patients with T1D have advocated for the right to have options to fit personal needs.

However, as the authors from the Barbara Davis Center for Diabetes at the University of Colorado note, the goal of administering insulin to people with diabetes is not simply to keep them alive but also to reduce the micro- and macrovascular complications the disease can cause; these are more likely if a patient experiences chronic swings in glucose levels and multiple episodes a day of hyper- or hypoglycemia.

While the old measure of health for a person with T1D was limited to the periodic glycated hemoglobin (A1C) test, more recently, the time-in-range (TIR) measure has gained recognition. As the Colorado authors write, today, the major treatment goal is to keep the glucose range between 70 mg/dL and 180mg/dL for 70% of the time, while maintaining an A1C of 7% or less to minimizing hypoglycemia exposure. Multiple studies show that AID systems offer superior TIR and are a game-changer for parents who seek peace of mind as they send children with T1D to school or hope to ease them into sports or activities.

The authors cite multiple factors for why some patients have not embraced AID technology, which under FDA guidelines have 3 distinct components: a continuous glucose monitor (CGM), which reads blood glucose levels; a pump to deliver insulin; and an algorithm that uses data collected from the CGM to send commands to the pump.

Although AID technology has become increasingly smaller, more discrete, and less burdensome, it still must be worn on the body. The authors identified cosmetic impact and the potential for skin injury as 2 factors that limit AID uptake. Other factors include the possibility that the device may limit physical activity. The authors also list “lack of access related to incomplete coverage and high cost,” along with racial and ethnic disparities, which could be tied to provider or patient biases about device use. Finally, the authors list “psychosocial barriers.”

Physical limitations. Patients and some parents of children with T1D have expressed caution about a having device attached to the body in some studies, although youth with T1D are among the most common users of AID systems. Over time, as children with T1D reach their teenage years, concern over the look of the device and being different from others emerges, especially among females, according to the authors. They cited studies that found skin irritations were common; this was reported by nearly 90% of those using continuous subcutaneous insulin infusion and nearly 80% using CGM.

Ability to use technology. Successive upgrades in automated systems have lightened the load on people with diabetes or their parents, but there remains a requirement on the part of the users to understand how to navigate the system. “This causes concern for some that the technology may be too complicated for them to confidently utilize and is often noted as a barrier to uptake of these devices,” the authors wrote. “Parents of children with T1D sometimes describe concern regarding malfunction and risk of hypoglycemia associated with pump use, despite research suggesting pump use is associated with reduction in hypoglycemia.” For some, studies suggest, using AID technology may initially increase the sense of burden, although this will decrease over time.

Burdens related to the health care team. The authors cited 3 issues: providers who resisted using new technology, providers who acted as “gatekeepers” to technology if people with diabetes did not have a history of checking blood glucose at least 4 times a day, and those providers who did not offer telehealth support to patients who uploaded their CGM data, a feature for all AID systems.

Cost and coverage. The authors cited multiple studies that found cost was a major barrier to AID uptake among those with low incomes, and a reason why those who started CGM stopped using it. Lack of insurance coverage, inadequate coverage, or the burden of having to spend hours on the phone with insurers were also cited. However, the perceived benefit of AID was often very personal, the authors found. “Most participants discussed weighing cost against benefit of devices, and some anticipated the cost to be too great to consider uptake of the devices, while others felt the benefits outweighed the costs, with one participant stating, ‘I would sell my house … I would do whatever I had to do.’”

Issues with cost and type of coverage are tied to the disparities in who uses AID. Data show that non-Hispanic White and female youth are more likely to use insulin pumps than other groups, the authors found. Being from a high-income family and having private health coverage also increased the odds, especially in the pediatric population, and the gap in technology use between high-income and low-income groups is growing wider, the authors said.

Depression and anxiety. A major benefit of AID use is increased sleep among parents of children with T1D, studies show. While the use of these systems is known to decrease the chance of hypoglycemia, which would seem to ease depression and anxiety, the authors cited studies that found for a subset of patients, fear of device malfunctioning has the opposite effect.

The authors state that while cost and coverage remain concerns, in the United States, Medicare coverage is improving, and recent actions that link coverage to “modern device use profile and evidence-based requirements” are encouraging.

Reference

Pauley ME, Berget C, Messer LH, Forlenza GP. Barriers to uptake of insulin technologies and novel solutions. Med Devices (Auckl). 2021;14:339-354. doi:10.2147/MDER.S312858.