Insulin Pumps Ease Diabetes Care. So Why Are Black Patients Less Likely to Get One?
Insulin pumps can help folks with type 1 diabetes get better control of their disease and minimize how often they inject insulin, and use of the devices has taken off in the past 20 years.
That's the good news from a new study.
The not-so-great news is that a large gap in who is using these insulin pumps remains. Specifically, white patients are twice as likely to receive an insulin pump as Black patients, and better-educated, wealthier people are also more likely to be using one.
"The big message is that over a 20-year period, we saw a pretty large increase in insulin pump use across all patients, but no change in distribution by race or socioeconomic status," said study author Dr. Estelle Everett, an assistant professor at the David Geffen School of Medicine at the University of California, Los Angeles.
"Despite the overall increase, most populations are really not able to benefit from insulin pump use and these are the groups who have more challenges managing their diabetes and a higher risk of complications, so they may actually gain the most benefit from diabetes technology," she said.
Unfortunately, such race and socioeconomic disparities exist throughout medicine. "This study is another example of a larger issue in the medical field," Everett said.
People with type 1 diabetes produce little to no insulin, the hormone tasked with helping blood sugar or glucose enter cells to be used as energy. When insulin is in short supply, glucose can build up, causing such symptoms as extreme fatigue, blurry vision, weight loss and confusion. This is why people with type 1 diabetes must take insulin throughout the day.
Enter insulin pumps. These are small, computerized devices that deliver insulin in a continuous fashion or as a surge "bolus" dose around mealtime. They drastically reduce the number of times a person with type 1 diabetes must inject insulin, help control blood sugar levels, improve quality of life and lower diabetes-related stress.
Exactly why uptake of these devices is so low in some groups isn't fully understood, but there are likely many reasons, including insurance barriers and provider bias in terms of to whom they recommend the technology, said Everett.
For the study, researchers looked at data about insulin pump use among youth under 20 during four periods between 2001 and 2019: 690 young people with type 1 diabetes in 2001-2005; 1,706 in 2006-2010; 2,385 in 2011-2015, and 2,257 in 2016-2019.
Overall use of the pumps grew from about 32% of people with type 1 diabetes to 59% between 2001 and 2019. By the study's end, insulin pump use was 67% among white patients; 41% among Hispanic patients; 29% among Black patients, and 46% among other racial and ethnic groups.
In addition, 70% of people with college degrees used insulin pumps, compared with 56% of those with some college; 40% of high school graduates, and 18% of those with no high school education, the study showed.
There were also disparities in insulin pump use based on household income.
Almost 75% of people with incomes of $75,000 or more used insulin pumps, compared to 66% of those with household incomes of $50,000 to $74,999; 51% with household incomes of $25,000 to $49,999, and 41% with incomes under $25,000, the researchers reported.
This needs to change, Everett said.
"People with type 1 diabetes, at minimum, have to inject insulin four times a day before every meal and then at bedtime, and not having to inject yourself offers big benefits and reduces stress related to diabetes," she said.
Today's insulin pumps have many sophisticated bells and whistles, including variations of insulin through the day and a special bolus (or single large) dose if a person eats or exercises. They can be synced with continuous glucose monitoring as well, Everett said. Many insurance companies cover the cost of pumps, but people must typically meet strict criteria first.
If you have type 1 diabetes, ask your doctor about insulin pumps, Everett suggested.
"Bring it up with your doctor and say, 'I am interested in this technology,'" she said.
The study was recently published in the journal Diabetes Technology & Therapeutics.
Dr. Charlotte Chen, a pediatric endocrinologist at Montefiore Health System in New York City, reviewed the findings.
"Despite the rapid advancement in diabetes technology and increase in insurance coverage, we continue to see these inequities in clinical settings," Chen said. "It is very concerning and a huge problem in diabetes care."
Potential drivers of these disparities include provider bias and financial barriers, Chen said.
"Other potential barriers to device use include psychosocial, cultural, familial and individual factors," she said. "Mistrust of the medical community is another commonly cited factor driving the inequities in diabetes device use."
More research aimed at reducing the gap in use of diabetes technology is needed, Chen said.
"Addressing social determinants of health can help as well," she said. "Most importantly, insurance and diabetes device companies should make the affordability and accessibility of diabetes devices a priority."
Recent data found that Black people had higher rates of severe diabetes-related complications compared with white folks.
"These complications are severe and life-threatening, and insulin pumps can help prevent these acute and chronic complications," Chen said.
There is also a concern that these gaps will widen with the new automated insulin-delivery systems, worsening health inequality for subsets of youth with type 1 diabetes.
The American Diabetes Association has more on the benefits of insulin pumps.
SOURCES: Estelle Everett, MD, assistant professor, medicine, Division of Endocrinology, Diabetes and metabolism, David Geffen School of Medicine, University of California, Los Angeles; Charlotte Chen, DO, pediatric endocrinologist, Montefiore Health System, New York City; Diabetes Technology & Therapeutics, Nov. 29, 2022