Comparison of Socioeconomic Disparities in Pump Uptake Among Children With Type 1 Diabetes in 2 Canadian Provinces With Different Payment Models

Abstract

Key Points Question Are socioeconomic status disparities in insulin pump uptake in children with type 1 diabetes (T1D) different under the fully funded government program in Québec and the partially funded program in Manitoba? Findings In parallel, population-based cohort studies including 3555 children with T1D, increasing material deprivation was significantly associated with decreased pump uptake in both Québec and Manitoba. Socioeconomic status disparities were statistically significantly greater in Manitoba than Québec. Meaning The findings of this study suggest that full financial coverage for insulin pumps may partially mitigate the observed socioeconomic status disparities in uptake and may be a model to improve access for children with T1D.

Persistent Socioeconomic Disparities in Insulin Pump Uptake Despite Universal Health Coverage—Nonmonetary Drivers in Insulin Pump Use

“…In addition, although mitigating some of the disparate access to diabetes management devices based on cost, the pump financing programs described in this article perpetuate underlying disparities. 1 The insulin pump funding programs in both provinces had prohibitive requirements for eligibility, including the ability to regularly monitor blood glucose levels and attend pump trainings and diabetes visits. In Manitoba, the pump program also required patients to maintain hemoglobin A 1c levels less than 10% and have fewer than 2 episodes of diabetic ketoacidosis in the past year.…”

“…Limited studies have begun to investigate the perspectives of patients and families from low SES and diverse backgrounds, and their findings suggest the importance of shared decision-making and understanding of patient and family preferences . The study conducted by Ladd et al further reinforces the importance of expanding research questions to better characterize and minimize the biases present in prescribing practices.…”

“…In their study on the use of insulin pumps among children with type 1 diabetes (T1D) in Canada, Ladd et al 1 used an interprovincial comparison to examine whether disparities in socioeconomic status (SES) were associated with use of insulin pumps despite government assistance. The authors assessed factors associated with insulin pump uptake in Québec and Manitoba and the use of province-level programs to support the financial costs associated with insulin pump use.…”

“…The authors' approach to a common limitation in health services research related to health care disparities is creative and mitigates the confounding related to the overlap between cost of diabetes management devices and the association between SES and use of the devices. 1 By noting that, even with universal financial coverage for insulin pump-related costs, individuals from neighborhoods with higher levels of material deprivation remained less likely to start using insulin pumps, the authors reported on what eludes health services researchers studying the use of diabetes management devices in countries without such expansive financial support for insulin pumps. This research design supports the conclusion that SES factors other than pure financial cost (ie, parental educational level, employment, race and ethnicity, and family structure) play a greater role in levels of insulin pump uptake than cost alone.…”

“…This research design supports the conclusion that SES factors other than pure financial cost (ie, parental educational level, employment, race and ethnicity, and family structure) play a greater role in levels of insulin pump uptake than cost alone. The authors aptly characterize this finding in the discussion, stating that "disparities may not be strictly owing to monetary concerns" 1 The US literature is lacking in its capacity to separate the association between the cost of devices and family income from other SES variables; although authors have attempted to conduct similar analyses using stratification by insurance type or poverty level, the health care system financing in the US precludes conclusive analyses such as those conducted by Ladd et al 1 However, even with this improved capacity to partially eliminate confounding, the authors were unable to control for what remains a challenging variable to capture and quantify in health care disparities research: implicit bias. Multiple findings within the study suggest the persistence of bias despite financial support (eg, the association between race and ethnicity and insulin pump uptake in Québec); yet, as the authors acknowledge, without explicit data about family preference and/or health care professional biases, they cannot measure its outcome.…”