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Socioeconomic status associated with adverse events in pediatric insulin pump users
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Canadian children of lower socioeconomic status using insulin pump therapy are at an increased risk for diabetic ketoacidosis, diabetes-related acute care and death vs. children from less deprived backgrounds, according to recent study findings.
In an observational, population-based cohort study, Rayzel Shulman, PhD, MD, FRCPC, of the department of pediatrics at the Hospital for Sick Children, University of Toronto, and colleagues analyzed the relationships between access to 24-hour support, socioeconomic status and risks for diabetic ketoacidosis (DKA) or death in pediatric pump users since a universal funding program for insulin pumps was instituted in Ontario. The researchers used Pediatric Diabetes Network survey data from 33 of 35 pediatric diabetes centers in Ontario (collected between January and June 2012) linked to population-based health administrative databases from November 2004 to March 2013 (n = 3,193). The cohort included all individuals who had an approved Assistive Devices Program application for pediatric pump funding between November 2006 and March 2011; index date was date of application for pump funding. Primary outcome was first admission for DKA or death; secondary outcomes included combined rate of diabetes-related admissions and ED visits. Researchers used a Cox proportional hazards model to test the association between risk for admission for DKA or death and 24-hour center support and material deprivation.
Within the cohort, the mean time on pump therapy was 3.77 years; the rate of DKA was 5.28 per 100 person-years; mortality was 0.033 per 100 person-years (fewer than six deaths). The risk for DKA or death for those in the most-deprived quintile was higher vs. the least-deprived quintile (HR = 1.58; 95% CI, 1.05-2.38) as was the rate of diabetes-related acute care use (RR = 1.6; 95% CI, 1.27-2). Researchers did not find an association between adverse events and 24-hour pump support.
“This suggests that, in Ontario, either availability of 24-hour support may not be an important gap in service delivery or that barriers to its effective use may exist such that its benefits were not realized,” the researchers wrote. “Future research should more closely examine potential barriers to accessing 24-hour telephone service care, as well as the full range of potential benefits, including impact on parental anxiety and its ability to reduce disparity in [socioeconomic status] of diabetes outcomes.”
Higher HbA1c, prior DKA, older age and being followed at a center with a higher nursing patient load were all associated with a higher risk for DKA or death, the researchers wrote. Having diabetes for at least 5 years was associated with a lower risk for DKA or death (HR = 0.76; 95% CI, 0.64-0.89).
Diabetes-related admissions or ED visits per person ranged from 0 to 30; 70% of children had no events. The rate of diabetes-related admissions and ED visits was 14.73 per 100 person-years.
“Even in the context of a universal access health care system, our hypothesis about [socioeconomic status] was confirmed,” the researchers wrote. “Individuals who were more deprived had both a higher risk of DKA and a higher rate of diabetes-related admissions and ED visits, adding evidence to an established body of literature suggesting that lower [socioeconomic status] is associated with disparities in diabetes management and outcomes.”
The researchers speculated that the disparity may relate to the additional financial burden of the uncovered 25% (800 Canadian dollars) of the annual cost of the insertion sets required for pump therapy, which may restrict the ability of lower-income families to purchase glucose test strips, which are not universally covered.
“Decreased access to test strips may restrict the frequency of blood glucose monitoring, known to be associated with diabetes outcomes,” the researchers wrote. – by Regina Schaffer
Disclosure: The researchers report no relevant financial disclosures.
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