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Low socioeconomic status is associated with adverse events in children and teens on insulin pumps under a universal access program: a population-based cohort study
  1. Rayzel Shulman1,2,3,4,
  2. Therese A Stukel3,4,
  3. Fiona A Miller3,5,
  4. Alice Newman4,
  5. Denis Daneman1,2,
  6. Jonathan D Wasserman1,2,
  7. Astrid Guttmann1,2,3,4
  1. 1Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  2. 2Sickkids Research Institute
  3. 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  4. 4Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  5. 5Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto, Ontario, Canada
  1. Correspondence to Dr Astrid Guttmann; astrid.guttmann{at}


Objective To describe adverse events in pediatric insulin pump users since universal funding in Ontario and to explore the role of socioeconomic status and 24-hour support.

Research design and methods Population-based cohort study of youth (<19 years) with type 1 diabetes (n=3193) under a universal access program in Ontario, Canada, from 2006 to 2013. We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. The relationship between patient and center-level characteristics and time to first diabetic ketoacidosis (DKA) admission or death was tested using a Cox proportional hazards model and the rate of diabetes-related emergency department visits and hospitalizations with a Poisson model, both using generalized estimating equations.

Results The rate of DKA was 5.28/100 person-years and mortality 0.033/100 person-years. Compared with the least deprived quintile, the risk of DKA or death for those in the most deprived quintile was significantly higher (HR 1.58, 95% CI 1.05 to 2.38) as was the rate of diabetes-related acute care use (RR 1.60, 95% CI 1.27 to 2.00). 24-hour support was not associated with these outcomes. Higher glycated hemoglobin, prior DKA, older age, and higher nursing patient load were associated with a higher risk of DKA or death.

Conclusions The safety profile of pump therapy in the context of universal funding is similar to other jurisdictions and unrelated to 24-hour support. Several factors including higher deprivation were associated with an increased risk of adverse events and could be used to inform the design of interventions aimed at preventing poor outcomes in high-risk individuals.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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