Prevalence and geographical distribution of insulin pump therapy in the Central Denmark Region and its association with metabolic parameters
Introduction
Within the last decades, insulin treatment of patients with type 1 diabetes has evolved and now includes different types of insulin and treatment strategies, typically multiple daily insulin (MDI) regimens or continuous subcutaneous insulin infusions (CSII). CSII was introduced in the 1970s [1] as a means to achieve and maintain strict control of blood glucose in patients with type 1 diabetes. Owing to its continuous basal insulin substitution, CSII can mimic a physiological situation, and furthermore, the basal and bolus functions of the pump allow for constant adjustment of requirements and flexibility in timing and amounts of nutritional intake and physical activity. CSII has been shown beneficial in pregnancy, in patients experiencing dawn phenomenon and in those with hypoglycemia unawareness [2]. It is indisputable that intensive insulin treatment improves metabolic control and thus reduces the risk of microvascular complications in patients with type 1 diabetes [3]. Several studies show that insulin pumps provide better glycemic control than MDI treatment [2], [4], [5], [6], and some studies indicate other benefits of CSII, including a reduction of total insulin dose, lower incidence of severe hypoglycemia and decreased glycemic variability [2], [7]. Moreover, a recent Swedish study has described a lower all-cause mortality, lower risk of fatal coronary heart disease, and lower risk of fatal cardiovascular disease among CSII users compared to MDI treated patients [8].
Despite the benefits of CSII, the access to insulin pumps remains limited in many European countries. The main reasons are considered to be the cost of the devices and lack of trained physicians to introduce pump therapy to the patients. Pump use is, however, increasing, particularly in pediatric populations [9].
In Denmark, the Danish National Board of Health recommends that clinicians consider pump treatment in patients with type 1 diabetes with a HbA1c > 7.0% (53 mmol/mol), multiple incidents of hypoglycemia despite optimal treatment, or hypoglycemia unawareness. A pump candidate has to be (1) Able to check blood glucose at least four times daily (2) Able to administer insulin four or more times a day (3) Motivated to optimize glycemic control and (4) Willing to carry out a complex insulin therapy regime and maintain contact with the clinical team [10]. Although such guidelines have been established, it is plausible that there is heterogeneity in the distribution of pump use throughout hospitals in Denmark. Only few studies have evaluated the prevalence and distribution of CSII in adults with type 1 diabetes [5], [7], [11] as most studies focus on children treated with CSII [12], [13], [14], [15]. A Danish national questionnaire study from 2003 recorded that 142 adults and no children were treated with CSII in Denmark [16], but no study has ever described the distribution of pump users in different hospitals in Denmark. Therefore, the aim of this study was to present an up-to-date description of the prevalence and distribution by hospital of CSII use among adults with type 1 diabetes in the Central Denmark Region and to compare metabolic control in CSII-treated patients to those treated with MDI.
Section snippets
Setting
The Danish National Health Service provides all Danish residents (approximately 5.6 million) with equal tax-supported health care, including partial reimbursement for prescribed medications, such as glucose-lowering medication. In detail, five Danish geographical regions provide primary and secondary health care, including outpatient clinic services and cost coverage of insulin pumps for type 1 diabetes patients [17]. The Central Denmark Region (13.000 km2) is the second largest Danish region
Data completeness
When cross-checking the DADR and the medical records, an extra 115 CSII users were added to the cohort, resulting in 828 CSII users and 3081 MDI treated. The data completeness was higher than 96.6% for all variables, except weight, height and BMI, which had a completeness of 94.9, 94.6 and 92.7% respectively. (The specific data completeness is shown in supplementary Table 1).
Basic characteristics and medication use
In the period 2014/2015, there were 3909 adults with type 1 diabetes patients living in the Central Denmark Region.
Discussion
The aim of the current study was to evaluate the prevalence and distribution by hospital site of CSII use among adults with type 1 diabetes in the Central Denmark Region, and to compare metabolic control in CSII-treated patients to those treated with MDI. Overall, we found that 21% of patients with type 1 diabetes were treated with CSII, but the proportion of patients treated with CSII differed significantly between hospitals ranging from 12.0% to 31.1%. Our findings differ from a Canadian
Acknowledgements
UK, LRM, LB, and DW are affiliated to the Danish Diabetes Academy, which is funded by the Novo Nordisk Foundation.
References (18)
- et al.
Turkish pediatric research group. evaluation of therapeutics management patterns and glycemic control of pediatric type 1 diabetes mellitus patients in Turkey: a nationwide cross-sectional study
Diabetes Res Clin Pract
(2016) - et al.
Danish society for diabetes in childhood and adolescence. quality of life in Danish children and adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections
Diabetes Res Clin Pract
(2014) - et al.
Continuous subcutaneous insulin infusion: an approach to achieving normoglycemia
BMJ
(1978) - et al.
Continuous subcutaneous insulin infusion (CSII) in the Veneto region: efficacy, acceptability and quality of life
Diabet Med
(2002) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus
N Engl J Med
(1993)- et al.
Continuous subcutaneous insulin infusion versus multiple daily injections in patients with diabetes mellitus: systematic review and meta-analysis
Diabetologia
(2008) - et al.
Changes in HbA1c and weight following transition to continuous subcutaneous insulin infusion therapy in adults with type 1 diabetes
J Diabetes Sci Technol
(2016) - Clements M, MatulevicieneV, Attvall S, Ekelund M, Pivodic A, Dahlqvist S, et al. Predicting the effectiveness of...
- et al.
Prevalence of insulin pump therapy and its association with measures of glycemic control: results from the Canadian study of longevity in type 1 diabetes
Diabetes Technol Ther
(2016)
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