Study Highlights Persistent Racial Disparities in Insulin Pump Use Among Children With T1D

Racial disparities in insulin pump use among children with type 1 diabetes (T1D) have persisted over the past 15 years, independent of socioeconomic status (SES), according to study results published in the Journal of Pediatric Nursing.

Insulin pumps are widely used to ensure optimal glycemic control in patients with T1D and, when used correctly, can significantly reduce the incidence of disease complications. Currently, more than 60% of youth use insulin pumps, and the technology has been proven to be associated with fewer severe hypoglycemia events and improved quality of life in addition to improved glycemic control.

However, insulin pump therapy does carry risks of interruptions to insulin delivery or action due to insulin pump failure, infusion set blockage, infusion site problems, or insulin stability issues. If undetected, these complications can lead to ketoacidosis or hyperglycemia.

“In light of the inherent risks of insulin pump use and the maintenance required, a key component to prescribing pump therapy has been providers’ judgement regarding ‘best’ candidates—those who are perceived to have the understanding and commitment to master basic diabetes self-management behaviors,” the authors wrote.

Previous studies have found significant disparities in application of insulin pumps. In particular, youths who are older, are male, from racial or ethnic minorities, have lower SES, or are from single-parent households are significantly less likely to use insulin pumps.

Additional research has suggested that “provider biases related to stereotypes regarding minorities’ competence and behaviors contributed to reduced rates of pump use in non-Hispanic Black (NHB) and Hispanic families.”

To determine if the gap in insulin pump therapy use among Black and White youth with T1D has widened or narrowed over the past decade, researchers at the Children’s Hospital of Philadelphia conducted a retrospective chart review. Data extracted from every second year from 2011 to 2020 were assessed and combined with historical data available from 2005.

All children included in the review were 18 years or younger, had a diagnosis of T1D, and attended an outpatient clinic appointment once in 2005, 2011, 2013, 2015, 2017, or 2019. Participants were excluded if their ethnicity or race was not Hispanic, non-Hispanic White (NHW), or NHB.

“Data were extracted from the latest attended outpatient diabetes appointment on each of the study years,” authors wrote. “For children seen in 2011–2019, age, sex, race, health insurance status (private versus government insured as a proxy for socioeconomic status), duration of diabetes, insulin pump use and most recent hemoglobin A1C measurement were extracted.”

A total of 1212 children (988 NHW, 171 NHB) were included in the data from 2005, and the number increased to 1519 (1189 NHW, 205 NHB, and 125 Hispanic) in 2019. Between 2011 and 2019, no significant differences in age, sex, or duration of diabetes by race were found. However, rate of insulin pump use increased from 9% in 2005 to 57.6% in 2019.

Data showed that between 2011 and 2019:

• The odds ratio for NHW vs NHB children using an insulin pump was 3.2 (95% CI, 2.2-4.8) in 2011 and 2.6 (95% CI, 2-3.2) in 2019.
• The odds of Hispanic children using an insulin pump were also higher than NHB, although the magnitude of this difference was lower (1.3 [95% CI, 1.1-1.6] in 2011 and 1.3 [95% CI, 1.1-1.5] in 2019).
• In every year, significantly more NHB than NHW children had government insurance (P < .001), although this was not always the case for NHB vs Hispanic children (2011: P = .1; 2013: P = .003; 2015: P = .04; 2017: P = .2; 2019: P = .9).
• Regardless of SES, NHW children were significantly more likely than NHB children to be treated with insulin pumps for each of the years, 2011, 2013, 2015, 2017. and 2019 (P < .001 for all).
• The most recent data show that pump use in NHW children with government insurance was 2.2 times higher than in NHB children, and this disparity was similar in children with commercial insurance: 1.8 times higher in NHW children.
• NHW children with government insurance were 1.4 to 1.7 times more likely than NHB children with commercial insurance to be prescribed insulin pumps from 2011 to 2019.

In total, compared with data from 2005, insulin pump use in 2011 increased 5-fold in NHW children (53%) compared with a 3-fold increase in NHB children (16%). In the subsequent 9 years, the disparity slightly widened, as insulin pump use rates increased by around 10% in both NHB children and NHW children (25% vs 65%, respectively).

Researchers hypothesized that “this inequity in the use of insulin pumps among children with T1D may play a role in the racial disparities in clinical outcomes seen in this condition as NHB children also have worse glycemic control and higher rates of complications of the disease.”

Although patient SES is commonly proposed as a factor explaining disparate outcomes among youth with T1D, the current study found disparities persisted regardless of health insurance status. Indeed, NHW children with government insurance were 1.5 times as likely to use a pump than NHB children with commercial insurance.

Due to the single-center, urban setting of the study, authors cautioned that results may not be generalizable to other institutions.

“Regardless of the contributing factors, increasing diversity in the healthcare workforce or adding community health workers to the team may play an important role in overcoming these barriers to equitable care,” researchers concluded. “The extent of these disparities must be fully investigated through research with parents of children with diabetes, and with providers, to determine the contributing factors—including the impact of subliminal bias.”

Reference

Lipman TH, Willi SM, Lai CW, Smith JA, Patil O, Hawkes CP. Insulin pump use in children with type 2 diabetes: over a decade of disparities. J Pediatr Nurs. Published online October 1, 2020. doi:10.1016/j.pedn.2020.08.007