Volume 192 - Issue 2
Glycaemic control in patients with type 1 diabetes after provision of public hospital-funded insulin pumps
Author: Peter W Goss
Med J Aust 2010; 192 (2): 107-108. || doi: 10.5694/j.1326-5377.2010.tb03433.x
Published online: 18 January 2010
Published online: 18 January 2010
To the Editor: Our positive experience with insulin pump therapy (IPT) in children without private health insurance contrasts with that of Thong and colleagues,1 who found that IPT did not significantly reduce glycated haemoglobin (HbA1c) levels in uninsured adults.
IPT improves metabolic control, reduces the risk of microvascular complications and improves quality of life in children with type 1 diabetes mellitus.2,3 Private health insurance fully rebates the cost of an insulin pump, but many uninsured Australian children with type 1 diabetes are denied access to IPT because their family cannot afford the $8000 purchase price of an insulin pump. The other major impediment to using IPT is the paucity of access to skilled local IPT teams.
In November 2008, to improve access to IPT, the federal government introduced a means-tested subsidy (to a maximum of $2500 per child) to be administered through the $5.5 million Type 1 Diabetes Insulin Pump Program.4
By 30 June 2009, the program had subsidised only 31 children for insulin pump purchase (unpublished correspondence from the Hon Mark Butler MP, Parliamentary Secretary for Health, to Mr Darren Chester MP, Member for Gippsland, July 2009). The largest user of this scheme, Gippsland Paediatrics (a private practice in rural Victoria), commenced IPT in 11 of the 31 children. Through local service clubs and other charitable institutions, we raised the funds required to pay the $5500 balance for all 11 children.5 Six other financially disadvantaged Gippsland Paediatrics patients had obtained insulin pumps through grants or community fundraising before the government subsidy program was introduced. Thus we have experience of 17 children, aged between 4 and 18 years (mean, 10.8 years) who were recipients of “donor” pumps. This sample represents about a quarter of the local children with type 1 diabetes and almost two-fifths of the 46 patients we have commenced on IPT.
To evaluate the metabolic outcome of IPT for these 17 children, we conducted a retrospective analysis of glycaemic control by comparing the average level of HBA1c during the 12 months before commencing IPT with the most recent HbA1c level.
The pre-IPT mean HbA1c level of children using the donor pumps was 9.2% (SD, 1.45%), which fell to 7.6% (SD, 0.83%) (P < 0.001) after a mean IPT duration of 10.2 months (SD, 6.1 months). In children aged 12 years or under (10 patients), the mean HbA1c level fell from 9.0% (SD, 0.94%) to 7.6% (SD, 0.43%) (P < 0.001) after a mean IPT duration of 11.9 months (SD, 7.6 months). In the remaining seven patients, aged 13–18 years, the mean HbA1c level fell from 9.4% (SD, 2.0%) to 7.8% (SD, 1.43%) (P = 0.03) after a mean IPT duration of 7.6 months (SD, 1.4 months).
Gippsland Paediatrics uses the RADICAL (Rural Australian Diabetes — Inspiring Control Activity & Lifestyle) model of care.6 The model consists of a collocated multidisciplinary team, including a general paediatrician, diabetes educator and counsellor, with the patient and family receiving proactive emotional support, consistency of personnel, and point-of-contact HbA1c testing. We individualise our approach through regular case conferences and try to match therapy with desired lifestyle. Our study demonstrated that, using this model, IPT improves glycaemic control in uninsured children targeted by government policy — at least in the short term.
To improve short-term health and reduce long-term diabetic complications in families who cannot afford insulin pumps, government programs need to make IPT more accessible to those families and support local multidisciplinary IPT teams.2
Competing interests
Medtronic Australasia provided a grant to research and publish the results of our rural insulin pump program. Medtronic had no input into the content of this letter. I attended Australian Paediatric Society insulin pump workshops in 2008 and 2009 that were sponsored by Medtronic, Animas, Cosmo, Novo Nordisk and Lilly. I have received two Novo Nordisk regional diabetes grants for rural diabetes research.
Acknowledgements
Comments from Professor Kevin Grumbach and Professor Tom Bodenheimer are gratefully acknowledged.
References
- Thong KY, Fegan PG, Yeap BB. Glycaemic control in patients with type 1 diabetes after provision of public hospital-funded insulin pumps [letter]. Med J Aust 2009; 191: 291. 0_CHDJBGJB
- National Health and Medical Research Council. Clinical practice guidelines: type 1 diabetes in children and adolescents. Canberra: Commonwealth of Australia, 2005. http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp102.pdf (accessed Dec 2009).
- McMahon SK, Airey FL, Marangou DA, et al. Insulin pump therapy in children and adolescents; improvements in key parameters of diabetes management including quality of life. Diabet Med 2005; 22: 92-96. 0_i1091873
- Juvenile Diabetes Research Foundation. Type 1 Diabetes Insulin Pump Program. Frequently asked questions — patients. http://www.jdrf.org.au/s/media/insulin_pump_frequently_asked_questions.pdf (accessed Dec 2009).
- Australia, House of Representatives 2009, Debates, 16 June 2009. Mr Darren Chester MP. Gippsland electorate: insulin pump therapy program. http://www.openaustralia.org/debates/?id=2009-06-16.61.1 (accessed Dec 2009).
- Goss PW, Paterson MA, Renalson J. A “radical” new rural model for pediatric diabetes care. Pediatr Diabetes 2009 Sep 4. [Published online ahead of print.] DOI: 10.1111/j.1399-5448.2009.00594.x. 0_CBBGJAII