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Background:  Poor glycemic control is common in type 1 diabetes (T1D), with about 80% of adults having an A1c above the recommended target of <7%, and those with A1c >8.5% are at highest risk for complications. The burden of self-management often leads to nonadherence, but advances in diabetes technology, like insulin pumps and continuous glucose monitoring (CGM), can reduce this burden. Despite these benefits, common provider practices often exclude patients who could benefit most. To address these critical gaps, we propose a study focused on patients with poorly controlled T1D from two endocrinology clinics (one university and one academic safety-net). The knowledge gained from this study will help guide the management of poorly controlled T1D and help tailor treatment to the needs of this population with high potential for benefit from insulin pump use.

Objective: Evaluate the use of an automated insulin pump system in patients with poorly controlled T1D and assess clinical outcomes

Methods: We collected EHR data from two large health systems, a university hospital and an academic safety-net hospital (SNH). Eligibility criteria includes A1c ≥ 8.0%, using multiple daily injections, not using an insulin pump, and participants must speak English or Spanish and have insurance coverage for the insulin pump system (includes Medicaid) to be able to continue the pump after the study if they choose. Participants will be randomized to the insulin pump system or usual care. Current analyses will assess baseline characteristics of enrolled participants.  

Results: Currently, 29 participants have been enrolled. Average A1c at baseline was 10.13%. 90% of participants endorsed that their health insurance either completely covered or covered some of the costs of a glucometer and test strips. 31% of participants endorsed that the cost of their healthcare was a problem for them. At baseline, 55% of participants were using a CGM. Of the participants not using a CGM, 83% use a glucometer. For participants using a CGM, the average time in range was 39%. 76% of participants injected insulin using insulin pens only, with the rest using either a vial and syringe only or a combination of both insulin pen and vial and syringe. The most common reason for missing insulin was forgetting to dose, endorsed by 58% of participants.

76% of participants endorsed that any of their healthcare providers had recommended they use an insulin pump. 20% of participants endorsed not starting an insulin pump because of insurance coverage or cost of supplies. Other reasons for not starting the insulin pump for at least 4 participants included their physician thinking they were not a good candidate or their physician requiring a certain number of CGM readings or A1c level to start a pump.

Conclusions: This project demonstrates completion of study visits among individuals with poorly controlled T1D who are placed on an automated insulin pump system, which addresses the previously unaddressed feasibility of studying diabetes technology in those with poor glycemic control and diverse racial-ethnic or SES groups. Furthermore, this study identifies several barriers in accessing diabetes technology that participants faced at baseline.