Article Review: Commissariat et al, 2017

Article Review 
Written by: Lucy Casson RN, CDE, MA(Nursing)
Paediatric Diabetes Nurse Practitioner 
Lucy Casson received financial support for the writing of this material. Her opinion is solely her own.   

The Article “Insulin Pump Use in Young Children with Type 1 Diabetes: Sociodemographic Factors and Parent-Reported Barriers” (Commissariat et al, 2017) ¹ addresses the many reasons against the choice of insulin pump therapy for young children. Whilst published in 2017, sadly many of these issues are still relevant today.  Despite the wealth of research supporting the use of technology, particularly in this age group² the uptake is not what it should or could be.  Many of these are also experienced in my own clinical practice.

Parent perceptions of physical burden (citing those associated with tubing as one reason) are outweighing the benefits of therapy effectiveness [table 3, below], even when encouraged by their HCP to use it.

Despite this encouragement, parents felt the physical burden outweighed the clinical benefit, thus highlighting the importance for the HCPs to discuss all therapy options.

Discussion:

This article potentially raises the question of HCP tech bias and a lack of choice of technology to suit the family's need?  These factors are highlighted below.

• Reducing the barrier of unconscious HCP bias

Despite evidence to support the use of diabetes technology, some health care professionals still demonstrate a degree of unconscious bias about who should be offered or recommended insulin pump therapy. Some examples of this unconscious bias are perceived intellectual ability, language barriers, financial constraints and whether they are currently engaged with technology, for example, CGM. Current research states that our assumptions are in fact incorrect and often, the patients who are having the poorest glycaemic outcomes on injection therapy, may achieve the greatest improvements when technology is introduced^3,4.  This should present sufficient reason to change the practice of those health care professionals still only offering or recommending insulin pump therapy to those families that they feel ‘meet their criteria’. We should be offering a variety of diabetes technology options to all, as barriers such as cost are reduced. CGM subsidy for all ages has now been introduced and new payment models for Insulin Pumps have been developed.

• Standard of care or ‘luxury extra’? 

International research and diabetes governing bodies all agree that technology delivers the best clinical outcomes⁵, therefore we need to be using this evidence to lead our decision making.  As clinicians, I believe we need to shift our view away from thinking of diabetes technology as an ‘advanced’ way of managing diabetes and start thinking of it as our industry standard. 

• Myths and fears.

Our job as HCP’s is to dispel fears, myths and perceived issues around living with diabetes technology. I often see in my practice that expectations and perceptions of diabetes technology may be worse than the lived experience. As a Nurse Practitioner, providing counselling support for parents, helps them to make the best choices for their child.

• Reducing the barriers of cost and financial bias

Financial constraints are a recognised barrier to pump uptake, as per Table 3.  Providing choice in access, alongside product choice is important to families who often have the dilemma of having PHI, versus not committing to a product for 4 years. Subsidy exists for both PHI and personal pay pathways with Omnipod DASH® Insulin Management System. I have a number of families who have taken advantage of these options by using their health insurance, once confident in their decision. This is a unique option with Omnipod DASH®, which also justifies it as an option for lower income families, or those without health insurance.

• Does choice matter?

Standards of care recommend the following for patients living with type 1 diabetes: “the type(s) and selection of devices should be individualised based on a person’s specific needs, preferences, and skill level”⁶. Wearability of a device as a preference is an example of choices that patients can make and should be supported. A structured decision-making process helps to navigate needs, preferences, and skill level, in the discussion between HCP and patient.

In my practice there are patients for whom a tubed pump was simply not an option for various reasons (lifestyle, practicality, and wearability). By providing a choice of Omnipod DASH® System, these patients preferences to match their lifestyle were achieved, in addition to meeting their clinical goals.  In a continuously evolving technology landscape, it can be difficult to be unbiased in the decision-making process. Ultimately, patients will seek out what they want anyway, and I believe that as HCPs, we need to keep up to date in this fast-evolving space to support choice.