The impact of health insurance coverage on pediatric diabetes management

Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

Overweight and obese children with optimal control in the T1D Exchange Registry: How are they different from lean children with optimal control?

AIMS

Increased adiposity is a risk factor for suboptimal diabetes control and cardiovascular disease (CVD) complications. Our goal was to identify modifiable behavioral characteristics of overweight and obese pediatric patients with type 1 diabetes mellitus (T1DM) who achieve optimal glycemic control and to evaluate their CVD risk compared to lean patients. Our hypothesis was that optimally controlled obese and overweight participants require more total daily insulin and are at higher CVD risk compared to optimally controlled lean participants.

METHODS

We analyzed a cohort of 9263 participants with T1DM aged <21 years in the T1D Exchange Registry. Optimal diabetes control was defined as HbA1c ≤ 7.5% (58 mmol/mol). We compared factors that influence glycemic control in lean, overweight and obese participants with optimal vs. suboptimal control, using logistic regression.

RESULTS

Age, race, overweight status, continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) use were important variables influencing glycemic control. In the optimally controlled cohort, 27% of participants were overweight or obese versus 30% in the suboptimally controlled cohort (P < 0.001). Overweight and obese participants with optimal control were not significantly different from lean participants in terms of CSII use, total daily insulin dosage per kg of bodyweight, glucose checks per day, boluses with bedtime snack, use of CGM, but had higher LDL cholesterol and triglycerides, and lower HDL cholesterol (P < 0.05).

CONCLUSIONS

There were no differences in modifiable behavioral characteristics between the obese, overweight and lean optimally controlled participants. However, predictors of cardiovascular disease were higher in the overweight and obese group.

Socio-economic, demographic, and clinical correlates of poor glycaemic control within insulin regimens among children with Type 1 diabetes: the SEARCH for Diabetes in Youth Study

AIM

To examine the distribution and association of sociodemographic, adherence, and barriers-to-care factors in relation to glycaemic control within insulin regimens in US children with Type 1 diabetes in the SEARCH for Diabetes in Youth Study.

METHODS

Self- or parent-reported data from 1095 children with Type 1 diabetes aged 10-17 years were collected on insulin regimen, sociodemographics, diabetes self-management, diabetes-related family conflict and barriers to care. Multivariable logistic regression analysis identified poor glycaemic control correlates within each insulin regimen.

RESULTS

Participants included 694 children on insulin pump therapy, 188 receiving basal-bolus injections, and 213 on a mixed insulin regimen. Of these, 28.5%, 45.2% and 51.2%, respectively, had poor glycaemic control [HbA_1c ≥ 80 mmol/mol (9.5%)]. Family conflict between parent and child regarding diabetes management was the only factor significantly associated with poor glycaemic control in all insulin regimens (insulin pump, P≤ 0.0001; basal-bolus injections, P=0.0002; mixed insulin regimen, P=0.0103). For children on insulin pump, poor control was significantly associated with non-white race (P=0.0008), living in multiple households (P=0.0331), having Medicaid insurance (P=0.0090), and decreased insulin adherence (P<0.0001). For children on a mixed insulin regimen, living in multiple households (P=0.0256) and not spending enough time with healthcare provider (P=0.0058) correlated with poor control.

CONCLUSIONS

A high percentage of US children with Type 1 diabetes had poor glycaemic control, especially those not using an insulin pump. Early identification of children with risk factors associated with poor glycaemic control within insulin regimens and addressing diabetes-related family conflict may allow interventions to improve diabetes management.

Self-rated health among American adolescents with type 1 diabetes in the T1D Exchange Clinic Registry

BACKGROUND

The goal of this study was to examine the self-rated health (SRH) of adolescents with type 1 diabetes (T1D).

METHODS

A logistic regression analysis of baseline data from adolescents in the United States included in the T1D Exchange Clinic Registry in 2010-2012 was conducted. Participants were 13-18years old at the time of enrollment in the registry and had been diagnosed with T1D at least one year before enrollment (n=5799).

RESULTS

Half (49.0%) of the participants were female, 46.3% were ages 16-18years, 22.5% were non-white, 35.7% did not have private/military health insurance, and 78.8% had HbA1c levels >7.5%, indicating poor T1D management, 20.7% reported having diabetes-related stress often or very often, and 46.4% used insulin injections or pens rather than a pump. In total, 10.3% (n=600) of the participants rated their health as poor or fair and 59.3% (n=3439) rated their health as very good or excellent. Participants with poor or fair SRH were more likely than those with very good or excellent SRH to be female (adjusted OR=1.7(1.4, 2.1)), 16 to 18years old (OR=2.1(1.7, 2.5)), and non-white (OR=2.7(2.2, 3.4)), to be without private or military insurance (OR=2.4(2.1, 3.0)), to have HbA1c levels >7.5% (OR=3.3(2.4, 4.7)), to report having diabetes-related stress often or very often (OR=6.1(5.1, 7.2)), and to use an injection or pen rather than a pump (OR=2.1(1.6, 2.4)).

CONCLUSIONS

Because adolescents with T1D who report lower SRH are more likely to have uncontrolled blood glucose and frequent diabetes-related stress, use of pumps and stress-reduction strategies may improve SRH among adolescents with T1D.

The impact of insurance coverage and the family on pediatric diabetes management

BACKGROUND/OBJECTIVE

The impact of family composition on glycemic control in children with type 1 diabetes remains unclear. We sought to evaluate the relationship between health insurance coverage, family composition, and insulin management, and assess their impact on glycemic control in a pediatric type 1 diabetes population.

METHODS

A retrospective chart review was completed for patients seen in the Pediatric Endocrinology Clinic at the University of Louisville in 2012.

RESULTS

The analysis included 729 patients with type 1 diabetes; 268 (37%) had public insurance while 461(63%) had private insurance. Compared with publicly insured patients, privately insured patients had higher rates of intensive insulin management with multiple daily injections (MDI) plans or pump devices (88 vs. 83.2%, p = 0.066) and lower HbA1c levels [8.57 vs. 9.39% (70 vs. 79 mmol/mol), p < 0.001]. Of the 729 patients, 243 were in single-adult homes (33%). Single-adult homes had higher HbA1c levels than two-adult homes, [9.3 vs. 8.6% (78 vs. 70 mmol/mol), p < 0.001]. Among publicly insured, there was no difference in HbA1c levels for single-adult vs. two-adult homes [9.4 (79 mmol/mol), p = 0.868]. For privately insured, patients in single-adult homes had higher HbA1c levels than peers in two-adult homes [9.2 vs. 8.4% (77 vs. 68), p < 0.001].

CONCLUSION

Insurance type and family composition have significant associative effects on glycemic control and insulin management that may be mitigated by insulin pump therapy. Identifying and addressing factors such as availability of resources, family education, and adult support and supervision, may help improve glycemic control in high-risk pediatric diabetes patients.

Young people with Type 1 diabetes of non-white ethnicity and lower socio-economic status have poorer glycaemic control in England and Wales

BACKGROUND

The impact of ethnicity and socio-economic status (SES) on glycaemic control during childhood Type 1 diabetes is poorly understood in England and Wales.

METHODS

We studied 18 478 children with Type 1 diabetes (< 19 years) attending diabetes clinics and included in the 2012-2013 National Paediatric Diabetes Audit. Self-identified ethnicity was categorized as white, Asian, black, mixed, other and 'not-stated' (did not to divulge ethnicity). A small area measure of SES was estimated from the Index of Multiple Deprivation. Multiple linear regression was used to assess associations between ethnicity, SES and glycaemic control (mean HbA_1c levels) accounting for age, gender and diabetes duration. The impact of insulin pump use on the ethnicity/SES-HbA_1c associations was tested in 13 962 children.

RESULTS

All children from minority ethnic groups had higher mean HbA_1c compared with white children, with largest differences observed in black and mixed ethnicities [8 mmol/mol (2.9%), 95% CI 5-11 and 7 mmol/mol (2.8%), 95% CI 5-9, respectively]. Lower SES was associated with higher mean HbA_1c with a dose effect. The lowest SES group had a mean HbA_1c that was 7 mmol/mol (2.8%) (95% CI 6-8) higher compared with the highest SES group, adjusted for ethnicity. Estimates for ethnicity were attenuated, but significant on adjustment for SES. Fewer non-white (white 20.3 vs. black 5.5%) and deprived (least deprived 21.1 vs. most deprived 13.2%) children were on insulin pump therapy. Ethnicity and SES remained significant predictors of HbA_1c after accounting for insulin pump use.

CONCLUSION

The association between ethnicity and glycaemic control persists after adjustment for deprivation and pump use. An alternative approach to intensive insulin therapy might benefit these vulnerable children.

Pediatric Diabetes Consortium Type 1 Diabetes New Onset (NeOn) Study: factors associated with HbA1c levels one year after diagnosis

OBJECTIVE

To identify determinants of hemoglobin A1c (HbA1c) levels 1 yr after the diagnosis of type 1 diabetes (T1D) in participants in the Pediatric Diabetes Consortium (PDC) T1D New Onset (NeOn) Study.

RESEARCH DESIGN AND METHODS

Diabetes-specific as well as socioeconomic factors during the first year following diagnosis were analyzed in 857 participants (mean age 9.1 yrs, 51% female, 66% non-Hispanic White) not participating in an intervention study who had an HbA1c value at 12 months.

RESULT

Mean ± SD HbA1c at 1 yr was 62 ± 16 mmol/mol (7.8% ± 1.5). In univariate and multivariate analyses, clinical center, non-Hispanic White race, private health insurance, living with both parents, higher frequency of self-monitoring of blood glucose (SMBG), and lower insulin requirements were associated with lower HbA1c concentrations at 1 yr (p < 0.01). No association was found with gender, age, Tanner stage, body mass index (BMI), diabetic ketoacidosis (DKA) at onset, number of positive autoantibodies or HbA1c at onset, or number of visits to diabetes physician during the first year.

CONCLUSIONS

White race, higher socioeconomic status, two-parent household, more frequent SMBG, and low insulin requirements are associated with lower HbA1c concentration 1 yr after the onset of T1D in children.

Coverage of insulin delivery devices and basal insulin analogs by US managed care organizations

OBJECTIVE

The perception in the US is that insulin formulations prescribed for type 1 and type 2 diabetes and delivered via insulin pens are more costly to patients than the same or similar products provided in vials, and that basal insulin analogs offered either in pens or vials are likewise more costly to patients than human insulin formulations. This study compares levels of coverage and copays by private and Medicare Part D plans for insulin pens and vials containing basal insulin analogs and for NPH formulations in vials.

METHODS

A commercially available formulary database (Access Point, Pinsonault Associates; updated quarterly) was analyzed as of January 2010 for private insurance plans and as of March 2010 for Medicare Part D plans. Analyses were performed for Tier-level coverage and copays per prescription for basal insulin analogs in pens and vials, and NPH in vials.

RESULTS

Basal insulin analogs in pens were covered by >91% of private and Part D plans. NPH coverage was reported by >92% of private plans and 69-95% of Part D plans, depending on brand. Irrespective of delivery mode, copays in the majority of private plans for basal insulin analogs and NPH were in the >$10-35 range. Copays were higher in Part D plans, with the majority of plans and subscribers in a >$35-50 range. Prior authorization was required by <10% of insurance plans for insulin analog pen prescriptions, and <3% of plans for insulin analog or NPH prescriptions in vials.

LIMITATIONS

This analysis was descriptive, copay stratification was not based on a statistical model but on copay ranges typically used by the plans, and there were no direct correlations performed on the numbers of subscribers per plan vs copay or Tier level.

CONCLUSION

These results counter the widely held perception that insurance coverage is less extensive for insulin pens vs vials. Medicare Part D plans often had higher copay requirements than private plans for the same product at the same copay Tier.