Loading ...

Accessibility to modern diabetes technology directly correlates with A1c among children with type 1 diabetes (T1D) globally, new research showed.

A cross-sectional study, conducted in 81 pediatric diabetes centers in 56 countries, found that a greater extent of reimbursement for continuous glucose monitoring (CGM), insulin pumps, glucose meters, and insulin was associated with lower A1c levels.

The survey, conducted from March to May 2024, revealed an approximate 2 percentage point difference in A1c between those with full reimbursement vs limited or no reimbursement. The findings were published online in JAMA Network Open by Alzbeta Santova, MD, of the Department of Pediatrics, Motol University Hospital, and Charles University, both in Prague, Czechia, and colleagues.

“We conclude that the greatest challenge to achieving global equity in diabetes outcomes lies in the unequal access to modern technologies for all children with T1D. While some countries advance toward comprehensive diabetes management, others still struggle with basic access to life-preserving insulin. This stark disparity underscores the urgent need for collective action,” Santova and colleagues wrote.

Increasing Access Equals Decreasing A1c

Survey responses were reported from pediatric diabetes centers in Europe (39 centers, 26 countries), Asia (19 centers, 12 countries), Latin and North America (14 centers, 10 countries), Africa (six centers, six countries), and Australasia (three centers, two countries), covering a total of 42,349 children with T1D. All participating centers are part of the SWEET initiative, a global platform aimed at optimizing diabetes care in children.

Based on the survey responses, Santova and colleagues categorized the countries (or regions within) as having full reimbursement for all supplies; limited reimbursement, as requiring copays or varying coverage policies; out-of-pocket payment with no reimbursement but possibility of purchasing the device or insulin; and no availability or reimbursement other than through sponsors or foundations.

Countries in which hybrid closed-loop systems were not available were automatically placed in the limited reimbursement category, even if the separate devices were fully available and reimbursed.

Full access or reimbursement for all the technologies and insulin were reported by 32 centers from 19 countries. In contrast, there was no access or reimbursement for any technology or insulin in eight countries (Bolivia, Ghana, Haiti, India, Mali, Nepal, Pakistan, and Senegal).

For each technology and insulin, mean A1c levels increased with decreasing accessibility. For CGM, A1c was 7.62% for full availability or reimbursement, 8.57% with limited reimbursement, 8.97% for out-of-pocket payment, and 9.65% for no availability or sponsor only (P < .001). For pumps, A1c rose from 7.61% to 8.42% to 9.31% to 10.10%, respectively (P < .001). Trends were similar for glucometers and insulin.

Proportions of children achieving A1c levels below 6.5% were 18.7% for full accessibility to CGM and 19.1% to pumps, significantly greater than centers with limited reimbursement (9.2% and 10.5%, respectively), out-of-pocket payment (8.4% and 5.0%, respectively), and no availability (7.8% and 5.1%, respectively).

According to the authors, “these data serve as a call to accelerate ongoing initiatives and inspire new, innovative solutions aimed at closing these gaps. Only by addressing these inequities can we ensure that every child with diabetes, regardless of their geographic or socioeconomic status, has the same opportunity in diabetes care and diabetes outcomes.”

Population-Wide Shift in A1c ‘Not Seen Before’

Asked to comment, Partha S. Kar, MD, Type 1 Diabetes & Technology lead of the National Health Service England, told Medscape Medical News, “As is now being shown in countries such as UK with widespread uptake of technology, there is now population-wide shift in A1c not seen before.”

He added, “If policymakers are serious about bringing A1c at a population level to sub-7.5% - 8% levels, then without technology it would be incredibly difficult to achieve, in my experience and opinion. Leaving the median A1c of a population at above 7.5%-8% goes with complications so that’s a decision regarding investment many will have to make in the near future.”

In an accompanying editorial, Elizabeth R. Seaquist, MD, professor of diabetes, endocrinology, and metabolism and co-director of the Institute for Diabetes, Obesity, and Metabolism at the University of Minnesota, Minneapolis, called it “striking” that access to technology in and of itself was associated with improved glycemic control, given that multidisciplinary team care is also needed to provide education and behavioral or psychological support.

“The commitment of the care team supporting patient-centered diabetes care probably has not changed over the decades, but the newest technologies provide tools to manage diabetes that surpass those available in the past,” Seaquist said.

Social determinants of health are a significant barrier to optimizing care in children with diabetes, she noted. “It will be important for caregivers to address such determinants in developing care plans for their patients,” Seaquist said.

Santova reported having no disclosures, although some of the coauthors reported having ties to device companies and other manufacturers. Seaquist reported receiving personal fees for service on an advisory board from Eli Lily and Company, outside the submitted work. Kar reported having no disclosures.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.