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18 Diabetes
Insulin pumps in diabetes care in Ireland
Written by Dr Katarzyna Gajewska, Lecturer, Department of Public Health and Epidemiology, RCSI
on the prescribed prescriptions.
Dr Katarzyna Gajewska, Lecturer, Those who met our definition
Department of Public Health and criteria were assessed as prevalent
Epidemiology, RCSI cases. The methodology of this
epidemiological study is better
described in the original article1.
Of 20,081 people meeting the
“T1D” criteria in 2016, the majority
Prevalence and uptake of CSII (85%) were adults (n=17,053).
Of the adult population, only
To assess the uptake of insulin 6.8% used CSII, and the uptake
pump therapy in Ireland, we had varied from as low as 2% (Co.
to estimate the prevalence of Roscommon) to 9.6% in Co.
T1D in Ireland first - there is no Kildare and Wicklow. Irish data
(6.8%) suggests under-utilization
diabetes registry in Ireland and this
of CSII in people over 18 in Ireland
data was unavailable. We used (Figure 1). When comparing
the Irish Health Service Executive with other countries where the
Primary Care Reimbursement reimbursement is offered, uptake
Service (HSE-PCRS) national in adults has been reported to vary
pharmacy claims database data from 9.4% in Scotland, to 15% in
from the years 2011-16 and England and Italy (data from 2017),
selected definition criteria based 21% in Denmark (in one region),
People living with chronic diabetes-related complications),
conditions in Ireland have their reduces the frequency of and
medicines fully reimbursed time spent in hypoglycaemia, is
through the Long-Term Illness cost-effective, and increases the
Scheme, which significantly quality of life when compared
reduces their health-related with the most popular treatment –
out-of-pocket expenses. Irish Multiple Daily Injections (MDI). But
people living with either type 1 anecdotal observation, discussions
or type 2 diabetes, have almost with people living with diabetes,
all of their medicines reimbursed, patient advocates and health-
including the costs associated care professionals (HCP), gave
with modern technology used me an impression that CSII is not
to better manage and control frequently used in Ireland. Thus,
diabetes: insulin pump therapy (or together with my supervisors:
Continuous Subcutaneous Insulin Prof. Seamus Sreenan (Clinician,
Infusion – CSII) and continuous Consultant Endocrinologist), Prof.
glucose monitoring (CGM). Ireland Kathleen Bennett (Epidemiologist),
is in the minority of countries and Dr. Regien Biesma (Public
worldwide, that offers almost full Health Specialist), we aimed to
reimbursement of costs associated investigate the uptake and access
with chronic conditions (together to CSII by adults with type 1
with, for example, France, or diabetes in Ireland as part of the
the UK etc.), thus people with HRB funded SPHeRE (Structured
diabetes in Ireland may consider Population and Health-services
themselves lucky. Research Education) doctoral
thesis conducted in RCSI:
The reimbursement, however, University of Medicine and Health
does not mean that the majority Sciences in 2015-2020.
of the type 1 diabetes (T1D)
population uses the best available
treatments. Insulin pump therapy
is accepted as an effective and
safe method of insulin delivery
for people with T1D of all ages,
and is recommended as a first-
choice treatment for pre-school
children. Many systematic reviews
and meta-analyses suggest that
the better accuracy of insulin
delivery in CSII provides better
treatment outcomes (blood-sugar Figure 1
control, reduced risk of developing
MARCH - 2021 • HPN | HOSPITALPROFESSIONALNEWS.IE
19
22% in Sweden (data from 2015),
and 37% in Germany (2017). In the Figure 2
United States (US), the uptake of
CSII is reported as high as 58%
in the clinics involved in the T1D
Exchange registry.2
Uptake of CSII is generally lower
in adults than in children and
adolescents, and Irish data are
no different - the uptake of CSII
was five-fold higher (34.7%) in
the paediatric population than in
adults. It also varied significantly
from 12.6% in Co. Mayo to 53.7%
in Co. Meath. The uptake of CSII
in children and adolescents in
Ireland is similar to that in the
UK where it was reported as
35.7% (England and Wales, 2019
Scotland, 2017), but still lower than
in other “Western” countries. The
highest uptake of CSII in children
and adolescents was observed
in Slovenia (74%), with Sweden,
Germany and Denmark also having
> 50% uptake. The evidence from
the US T1D Exchange registry
suggests an uptake of 60% in
the paediatric population in
20142 (Figure 2).
Availability of CSII in diabetes
clinics
The reasons behind the
underutilization in adults are partly
associated with poor access to
insulin pump therapy across the
country, and centralisation of type
1 diabetes services in Dublin.
According to the survey of all Irish
adult diabetes clinics conducted
in 2018, one-third of Irish diabetes
clinics (n=15) do not provide any
type of support for patients willing semi-structured interviews with awareness of such solutions is referral pathway) and the quality
to commence CSII or those who HCPs, key stakeholders, policy- also lower in areas of low uptake. of care and HCP expertise in this
are using pumps. Based on the makers, patient advocates and If there is only one clinic in the area is not standardized (CSII
survey findings, access to CSII pharma reps, and through focus county, and it is not offering not always included in specialist
was unavailable for 11% of adults groups with people living with insulin pump therapy, their choice training), and if capacity is poor
with type 1 diabetes, and uptake diabetes (PwD) in areas of high and of diabetes team or consultant (e.g., under-resourced clinics), CSII
was usually higher in the counties low uptake of CSII. This qualitative is limited. They can only access uptake appears to be impacted
where training to commence
study provided deeper insight into CSII privately, and overall they by individuals (HCP and patients):
CSII was offered. However,
the determinants of the uptake have to put much more effort their interest, leadership skills,
fewer than half of the diabetes
in Ireland. Firstly, all discussions to access CSII much more than willingness and motivation. These
clinics in Ireland offer training
highlighted inequality in accessing those living in areas where access factors may make the regional
to commence CSII, and even in
CSII in Ireland mainly related to a to CSII is easier more available. differences in accessing diabetes-
these clinics the uptake of CSII is
still low when compared to other place where a PwD lives. There The “Conceptual Framework related technology and the quality
countries’ national data. Those was general agreement among of accessing diabetes-related of care more evident. Moreover,
clinics were usually based in, and participants that the uptake of technology” presents four main according to the vast majority of
around Dublin, hence, the highest CSII is low in Ireland, and that the themes consisting of 18 categories. participants, endocrinologists are
uptake was observed in the East “postcode lottery”, understood as More detailed description available “the gatekeepers” to accessing
of Ireland. Except for Co. Galway, an unequal provision of services, in Acta Diabetologica, 58, 93–105 CSII. HCP and their attitude
the clinics in the West of Ireland exists. This postcode lottery (2021). https://doi.org/10.1007/ toward it as gatekeepers is
(Co. Limerick, Kerry, Greater Cork) ensues. If you live in the right s00592- 020-01595-5, or by e-mail absolutely huge if they don’t see
were not offering CSII support in place you get the best care, if request (katarzynagajewska@rcsi. the need for pump therapy, then
2018. In Co. Galway the uptake you live in the wrong place you com). The overarching themes it is going to be very challenging
was relatively high – mainly due to get screwed (Key Stakeholder 1). were (from the least frequently for you to get your hands on a
sufficient resources (i.e. the level discussed to the most): awareness, pump. So, they are a key barrier
of WTE for endocrinologists in one This inequality was “frustrating” structure, capacity and impact of or facilitator. Some consultants
clinic is the highest in Ireland)3. for all participants and it was an individual. are very supportive and others
“obvious” that low uptake is not so much. (Key stakeholder 2).
Barriers to accessing pumps: caused by the lack of local access The role of individual preferences
“postcode lottery” to CSII: participants from the areas The “gatekeeping” may partially
of low uptake have to travel, pay The main conclusion of this study be explained by the fact that a
The barriers and enablers to and spend their time to access is that if the structure of the specialist who provides diabetes
accessing insulin pump therapy care; thus, it requires significant health-service is insufficient (e.g., care in Ireland is also (mainly!)
by adults were explored through motivation and willingness. The lack of standardized criteria or a trained in endocrinology, and
HOSPITALPROFESSIONALNEWS.IE | HPN • MARCH - 2021
20 Diabetes
Grove (Department of Geography,
Dr Kataryzna Gajewska with NUIG Maynooth) for their help
Primary Supervisor Professor in data mapping, and the Irish
Seamus Sreenan at the European Endocrine Society for the travel
Association for the Study of grants to disseminate the findings
Diabetes (EASD) meeting in to the international audience.
Berlin 2018
References:
1) Gajewska KA, Biesma R,
Sreenan S, Bennett K.
Prevalence and incidence of
type 1 diabetes in Ireland: a
retrospective cross-sectional
study using a national pharmacy
claims data from 2016; BMJ
Open 2020;10:e032916 .
To conclude, this PhD research 2) Gajewska KA, Bennett K, Biesma
contributes to the scarce evidence R, Sreenan S. Low uptake
on access to CSII (or any other of continuous subcutaneous
complex diabetes technology) insulin infusion therapy in
for adult people living with people with type 1 diabetes in
diabetes. Although technological Ireland: a retrospective cross-
advancements in diabetes are sectional study. BMC Endocr
well-known and influence the Disord 20, 92 (2020). https://doi.
quality of diabetes care and the org/10.1186
lives of PwD, uptake is limited by
lack of individual motivation and 3) Gajewska KA, Biesma R,
interest, health system structural Bennett K, Sreenan S.
issues, service capacity, awareness Availability of and access to
and PwD demand. The results continuous subcutaneous insulin
of this study may inform HCP infusion therapy for adults with
a lot depends on the personal ways of “fighting” included: “being type 1 diabetes in Ireland. Acta
interest of the HCP. I am not vocal”; contacting politicians; and policy-makers regarding
gaps in the delivery of diabetes Diabetol 57, 875–882 (2020).
really a diabetes guy, I am more involving media and government https://doi.org/10.1007/s00592-
of an endocrinology guy (Key to “push” hospital management. care, and suggest solutions to
reduce the disparities in health 020-01497-6
Stakeholder 3). Specialists who are All participants agreed, however,
that adult PwD were generally service provision in the countries 4) Gajewska KA, Biesma R,
more interested in endocrinology
ess effective in advocating for the where reimbursement of diabetes Bennett K, Sreenan S. Barriers
than diabetes were seen as less
use of CSII than parents of children technology is offered. Such steps and facilitators to accessing
likely to offer CSII. Lack of interest
with diabetes, who were “more may include the development of insulin pump therapy by adults
in CSII, and leadership skills were
concerned with getting national guidelines, models of with type 1 diabetes mellitus:
a HCP-related barrier to CSII
the best available treatment for care, standardized HCP straining, a qualitative study. Acta
provision: If a consultant has no
their children”. diabetes education, and structured Diabetol 58, 93–105 (2021).
interest in insulin pump or never approaches to provide equal
trained, or an endocrinologist https://doi.org/10.1007/s00592-
The uptake of CSII in paediatric access to CSII across the country. 020-01595-5
who has no experience in that
and has no interest in developing patients might be higher in
children than in adults due to This research was funded by the 5) Policy brief: The uptake of insulin
it, it will never develop (Key Health Research Board (HRB) pump therapy by people with
Stakeholder 4). better awareness of its benefits,
and available policy documents SPHeRE/2013/1. We would like type 1 diabetes in Ireland: do we
(i.e. the pediatric model of care to thank Diabetes Ireland for their meet expectations? https://www.
“Fighting” for access support in data collection, Prof. sphereprogramme.ie/resources/
for CSII that prioritise access to
insulin pump therapy for children Ronan Foley and Mrs. Hannah policy-briefs/
There was a consensus among all
participants, that the main barrier under five). Reliable information
to CSII from the PwD side was about CSII should be provided
the lack of willingness to do so, to PwD in Ireland to enable them
or a lack of interest in diabetes. to make an informed decision
Some of them “don’t want to be regarding commencing CSII.
attached” to anything, or report Other facilitating aspects included:
individual respectful cooperation
that CSII does not suit their lifestyle
between diabetes teams and
and needs, and this preference
patients, better access to diabetes
should be respected. The lack
education, standardized “criteria”
of initiative and motivation to
to commence CSII, and awareness.
consider CSII might sometimes be
determined by poor empowerment,
diabetes stigma or even burnout,
or just no strong motivation and
capacity to “fight”. There was
agreement among all PwD in this
study that they have to fight to
access technology, in particular
in rural areas. I went into XXX
(consultant) and I was like: “it’s
as simple as this, I’m not leaving
until you give me a letter to go
to the YYY (clinic offering CSII)”.
I said “I’m done with injections” Insulin Pumps available in Ireland
like (Key Stakeholder 5). Other
MARCH - 2021 • HPN | HOSPITALPROFESSIONALNEWS.IE
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