The study found young adults had the lowest device uptake, as well as highest distress levels and the highest A1C.
Diabetes devices, such as continuous glucose monitoring (CGM) systems, have been shown to give patients greater glycemic control and limit events that could land them in the hospital. So what makes some people embrace technology while others don’t?
Even if cost isn’t a problem, nearly half of people with type 1 diabetes (T1D) say devices can be a hassle, according to a new study from Stanford University School of Medicine, published this week in Diabetes Care.
The results highlight the importance of design and ease of use for those who wear devices 24/7, something that the T1D community points out regularly. Well-known is the “Open Letter to Steve Jobs,” which DiabeteMine’s Amy Tenderich published in April 2007. In the letter, Tenderich pointed out the need for diabetes devices that were smaller and less obtrusive. Stanford’s study suggests there’s still room for improvement.
Researchers surveyed 1503 adults with T1D, and asked about 19 different barriers to using a device, gathering information to compare those who use device with those who don’t. While the participants ranged in age from 18 to 80, they had with a mean age of 35.3 years and mean disease duration of 20.4 years.
They were evaluated using the Diabetes Distress Scale, as well as scales that examined their general attitudes toward technology, as well as diabetes-specific technology.
Why don’t people with T1D use devices? According to the study, 47.3% of participants report modifiable reasons that relate to the devices being a hassle, including 34.8% who said they didn’t like having them on their body.
The researchers distinguish between “modifiable” barriers, such as comfort, too many alarms, or having people ask why a device attached to them; and “non-modifiable” barriers, such as cost and insurance coverage. This second set of barriers affected more than half of respondents, with the cost of supplies cited most frequently by 61.3% of respondents.
Researchers also found that CGM users (37%) were older than non-users (mean age 38.3 years vs 33.5 years) and had lived with diabetes longer (22.9 years vs 18.8 years). Not surprisingly, those who used technology had more positive attitudes about it and reported fewer barriers than non-users.
It’s worth noting that the need for CGM increases with age and disease duration; the longer one has T1D, the greater the likelihood a person becomes “hypo-unaware,” which means the person loses the ability to sense symptoms of hypoglycemia and faces increased risk, especially at night. There has been hope that FDA would add an indication to the approval for the Dexcom G5 to allow dosing off CGM, which many believe could pave the way for widespread Medicare coverage to T1D patients.
By contrast, this new study found that young adults, those aged 18 to 25 years, has the lowest CGM use—just 26% compared with 40% to 48% for other age groups. This group also had the lowest rate of insulin pump use at 64%, compared with 69% to 77% for the other age groups.
The 18 to 25 age group also had the highest diabetes distress levels, and, alarmingly, the highest levels of glycated hemoglobin at 8.3%, compared with 7.2% to 7.4% for other age groups.
“These findings highlight the need the need to address unique barriers to diabetes device use among young adults,” the authors wrote. “Given the substantially lower device uptake rates compared with older cohorts, access to devices and affordability may be primary barriers. However, the current findings point to more personal and social reasons for young adults declining or discontinuing device use, such as not liking how they look on one’s body and not wanting to attract attention.”
In years past, young adults had some of the highest uninsured rates. The Affordable Care Act has allowed this group to stay on their parents’ health plans through age 26—and bars plans from denying coverage for pre-existing conditions such as T1D. However, individual plans may still limit which devices they cover, and users face out-of-pocket costs. In an email, lead author Molly L. Tanenbaum said that 57% of the youngest adults reported that insurance was a barrier, athough psychosocial barriers played a bigger role in this group than for older adults.
Trang Ly, MD, vice president and medical director for Insulet Corporation, creator of the Omnipod, a tubeless pump worn under clothing that has attracted a younger patient base, said the findings of the Stanford study are important to the diabetes community.
“The benefits of the technology, such as reduced hypoglycemia and hyperglycemia, cannot be realized if patients do not feel comfortable and confident wearing the devices,” Ly said. “We’re pleased to see data that tells device manufacturers patients want wearable technology, an advantage Omnipod already offers.”
Tanenbaum ML, Hanes SL, Miller KM, Naranjo D, Bensen R, Hood KK. Diabetes device use in adults with type 1 diabetes: barriers to uptake and potential intervention targets [published online November 29, 2016]. Diabetes Care. doi: 10.2337.dc16-1536.