Increased adoption of the latest technologies to manage type 1 diabetes is being held back by a lack of knowledge of the benefits among clinicians in certain areas of England and Wales, leading to wide variations in access, say UK experts.
They argue that this patchy uptake, despite good evidence to show that patients experience reductions in HbA1c levels and hypoglycaemic episodes, is in turn holding back the introduction of modern ‘closed loop’ insulin delivery systems.
The experts were speaking during a dedicated session on access to technology at the Diabetes Professional Care Virtual 2020 meeting on November 11.
Session Chair Pratik Choudhary, professor of diabetes at the University of Leicester, said that, from a slow start, there has been in some instances, a "rapid" uptake of diabetes technology.
This has not been across the board for all technologies, however. He pointed out that the first use of insulin pumps was in 1979, and "we still haven’t reached 30% use" of the technology across the National Health Service.
In contrast, the uptake of the Abbott FreeStyle Libre glucose monitoring system has been much quicker, particularly in recent years, thanks to the device becoming available on prescription on the NHS in April 2019.
As reported by Medscape News UK, there was subsequently a more than 60% increase in its adoption by eligible type 1 diabetes patients up to August of that year, from 10.7% to 17.6%.
Session panel member Conn O'Neill, chair of the Association of British HealthTech Industries (ABHI) diabetes group, the UK diabetes-management industry body, and public affairs lead at Roche Diabetes Care, said that, since then, adoption has reached 30% of eligible patients.
He believes that this is "a good story not only for Libre but also for all other technology," from the most simple devices that "all diabetes patients use", such as needles and test strips, "through to the most advanced technology that’s available".
T1D '100 Times Easier'
Expanding on this theme, Dr Emma Wilmot, consultant diabetologist, University Hospitals of Derby and Burton NHS Foundation Trust, said that, in 2020, living with type 1 diabetes is "definitely 100 times easier than it was 50 years ago".
This is due to a range of technologies, "but with that comes a lot of challenges".
She pointed to research commissioned by Roche which showed that just 21% of 205 clinical commissioning groups in England, surveyed under a freedom of information request, offer continuous glucose monitoring (CGM) in line with National Institute for Health and Care Excellence (NICE) guidance.
Dr Wilmot also highlighted that it has been 12 years since the publication of a NICE technology appraisal setting out recommendations for insulin pump therapy in individuals with type 1 diabetes.
Yet the most recent data showed that uptake of insulin pump therapy by adult patients is 18% in England, 10% in Scotland and Northern Ireland and 6% in Wales, compared with 21% in Denmark, and 37% in Germany and Austria.
Data from the 2017–2018 National Diabetes Insulin Pump Audit also showed that there was a more-than 10-fold variation in device uptake among adult patients across England and Wales, ranging from over 45.0 to less than 5.0%.
The audit also showed that there is huge variation in insulin pump provision to children and young adults with type 1 diabetes, ranging from less than five percent of patients in some specialist services to over 80% in the best performing units.
"If you had a brother, a sister, a mother, a father with type 1 diabetes, would you want them attending a service that has less than five percent of people on pumps or would you want them attending a service that has more than forty percent of people on pumps?" Dr Wilmot asked.
She added that "we know" that insulin pumps reduce HbA1c levels and the incidence of hypoglycaemia, and "the fact that there is a variation is completely unacceptable".
Dr Wilmot continued that staffing is an important issue for the adoption of diabetes management technology.
Data from the audit showed that 24% of 115 specialist services had to stop insulin pump starts in the previous 2 years, with 70% citing staffing issues as the main reason.
"But that was before COVID-19," she said. "Think where we are now.
"Our services have been suspended, we’re in crisis mode, and I suspect a lot of services up and down the country are going to take months if not years to catch-up on their backlog of pump upgrades and pump new starts."
She continued that the barrier to uptake is not the technology itself, as Libre Freestyle has been adopted much more quickly than insulin pumps since its introduction in 2017.
While there are big differences between the two technologies, she believes that the story of CGM uptake "demonstrates that when everybody is pushing in the same direction, you can get access to the technology that’s needed".
Dr Wilmot continued: "For me personally, one of the fundamental differences between access to pumps and access to Libre is the person with diabetes.
"The fact that they were able to sample Libre, understanding the benefits and then fight with Diabetes UK for access, I think fundamentally started a rollercoaster here, and we have all been pushing ever since then."
This is despite insulin pumps having a higher level of evidence for HbA1c reduction and reduction in severe hypoglycaemic episodes.
Her experience is that patients report them to be "life-changing, in the same way that people come back to clinic and say that [Libre] is life-changing".
She added: "The difference is there’s a barrier to pump therapy," and that is a lack of understanding of insulin pump technology and its benefits among healthcare professionals.
For Dr Wilmot, this is a concern because "closed loop" automated insulin delivery therapy, which uses an algorithm-based system to combine an insulin pump and CGM, is "without a doubt the future of type 1 diabetes care".
"When you speak to people on these systems, they say their lives have fundamentally changed for the better, but if we’re to deliver this in the UK, we need to reflect on where we’re at and how we address the barriers.
"If we can’t get people onto pumps, if we can’t get people onto CGM, then we’re not going to be able to get [them] on closed loop systems.
"Across the board, like we did with Libre, as a community, we need to address this and push hard to make these technologies reach the people who need them the most."
This fits with a recent report from the Juvenile Diabetes Research Foundation, which states that not only should type 1 diabetes patients have more time with specialist healthcare professionals at appointments, but also that specialists should receive mandatory training in diabetes technology.
Consequently, Dr Wilmot urged that in every possible consultation, "think: ‘Does this person meet the NICE criteria’? If they do, discuss pump".
If clinicians don’t feel comfortable doing that, they should learn about diabetes technologies, she said, "or get a colleague to see them who understands pumps".
Healthcare professionals should also ask themselves whether they can have an 'informed discussion' with patients about closed loop systems.
Dr Wilmot added: "Playing devil’s advocate, should we be moving towards a point where if you’re working in type 1 diabetes that you have to have a basic level of training in pump therapy, in CGM…to be able to deliver that service?"
No funding declared.
Dr Wilmot declares speaker fees, research and educational grants from Abbott Diabetes Care, Dexcom, Diasend, Eli Lilly, Insulet, Medtronic, Novo Nordisk, Sanofi Aventis.
Mr O’Neill is an employee of Roche Diabetes Care.
Diabetes Professional Care Virtual 2020: Abstract Access to diabetes digital tech. Presented November 11.
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Cite this: Liam Davenport. Huge Variations in Access Holding Back T1D Tech Adoption - Medscape - Nov 17, 2020.