Diabetes Device Access Gaps Common, Affect Management

Medscape

a day ago

Gaps in access to prescribed diabetes technology are common, often arise from early device failure, and lead to disruptions in diabetes management, new research found.
The top three reasons for the gaps were delays caused by insurer requirements for prior authorization, problems with suppliers in processing requests for refills, and delays in obtaining updated prescriptions from physicians, according to the survey results, presented by endocrinologist Andrew Welch, DO, at the American Diabetes Association 85th Scientific Sessions.
The access problems were associated with higher A1c levels and lower socioeconomic status and were more common among patients who receive 30-day rather than 90-day prescriptions.
'Almost every single day this theme comes up with patients where they have prescribed diabetes technology supplies, but something happens to interrupt that supply and they're not able to use the system as intended,' said Welch, assistant professor of clinical medicine at the University of Cincinnati College of Medicine, Cincinnati, Ohio.
Among the 1969 survey respondents, 42.7% of continuous glucose monitor (CGM) users and 27.3% of insulin pump users reported one or more gaps in their supplies per year, while 12.7% reported access gaps for insulin. Early device failure contributed to the problem, with 42% of CGM users and 47% of insulin pump users reporting early failure of those devices more than 10% of the time.
David T. Ahn, MD, chief of diabetes services at Hoag Memorial Hospital Presbyterian, Newport Beach, California, told Medscape Medical News that those numbers are 'higher than I would have guessed, but I'm not surprised.'
Both Welch and Ahn noted that some patients struggle with technology gaps and product failures more than others.
'There's a group of people who don't report any problems with this, and then there's a group who has so many problems that it can take over the whole clinical picture of that person's diabetes care,' Welch said.
Ahn suggested a few workarounds, such as giving patients free samples or writing prescriptions for longer-lasting quantities of insulin and pump supplies, but that doesn't always work, he noted. For example, it's difficult to prescribe extra quantities of CGM sensors because they're labeled to last a specific number of days, Ahn explained. 'With sensors, it's a very challenging task. I personally have not seen it succeed.'
Handling all the prior authorization requests can also be a challenge in Ahn's practice, which focuses on type 1 diabetes management and has made recent efforts to optimize workflow, he said.
'It's our area of passion. But imagine a general endocrinologist helping people with thyroid and pituitary conditions or a primary care provider managing every condition in the book. It makes perfect sense that prior authorizations are going to be a huge bottleneck for getting these supplies authorized,' he said.
Physicians should be able to individualize diabetes device prescribing, Welch said. 'Insurance companies should cover the quantities of diabetes supplies based on published failure rate data, and/or based on physician-prescribed quantities, without hassle, prior authorization, or extra cost,' he said during his ADA presentation.
Access Gaps, Device Failures Common
The online 64-question anonymous survey was distributed in December 2023. Access gaps were defined as the inability to obtain prescribed supplies for diabetes technology for any reason, leading to the individual going without that supply for any duration of time. The survey was sent to about 46,000 email addresses of people in the T1D Exchange, of whom 2475 responded and 506 were excluded.
The respondents had a mean age of 48.8 years, diabetes duration 27.9 years, and mean A1c of 6.6%. Three quarters were female, 78% were college graduates, and only one quarter had annual incomes below $50,000. Two thirds (64%) had private insurance. Nearly all (96%) used CGMs and 80% used insulin pumps.
'This is a very motivated group of people who are engaged with their diabetes,' Welch noted.
While 57% of CGM users reported having no CGM supply access gaps in the past year, 18% reported one gap, 12% two, and 7% three. Of those reporting gaps, the average CGM user reported 2.6 access gaps per year.
Access gaps for CGM were significantly more common among those with lower incomes; those of a minority race/ethnicity; and people on Medicaid or with no insurance vs those with private insurance, Medicare, or Department of Veterans Affairs (VA) benefits, and for females vs males.
Gaps were less common with insulin pump supplies, with 72.7% reporting no gaps in the past year. However, 12.8% reported one gap, 7.2% two, and 2.5% three. Those with gaps reported an average of 2.4 gaps per year. Socioeconomic differences were similar to those seen with CGM access.
While 87.3% of insulin users reported no gaps, 6.2% reported one gap, 3.3% two, and 3.3% three in the past year. The average was 2.2 gaps per year.
'Fortunately, this was a smaller number and frequency, but it's still somewhat discouraging to consider,' Welch said.
The differences in gaps in all supply types were significant for all socioeconomic groups ( P < .05). For example, those on Medicaid had 2.1 annual CGM gaps per year, compared with 0.5 for those receiving VA health benefits.
Asked what they did to avoid access gaps, patients reported calling the company to request replacements if a device fails early, extending use of the supply longer than recommended, and having their health care provider prescribe extra supplies. Some reported obtaining supplies from other people with diabetes who have extras.
Access gaps were related to worse glycemic control. Individuals with A1c levels of 7.0% or less had approximately half as many gaps in access to all diabetes technology supplies and insulin compared to those with an A1c level > 7.0%. For CGM supplies specifically, the difference was 0.8 vs 1.5 gaps per year.
Patients who receive 90-day supplies reported half as many gaps as those who reported receiving 30-day supplies. With CGM, the difference was 0.8 vs 1.6 annual gaps.
The survey found that CGM sensor failure is very common, Welch said. Over half of respondents (50.8%) reported that their devices failed early or fell off 1%-10% of the time, another 21% reported early failures 11%-20% of the time, and only 7.3% reported zero failures.
Failure rates of more than 10% of the time were seen among all CGM brands, ranging from 39% with the Dexcom G6 to 53% for Abbott's FreeStyle Libre 3. For insulin pump failures, those proportions ranged from 34% with Medtronic's MiniMed 780G to 53% for Insulet's Omnipod 5.
The length of access gaps wasn't included in the T1D Exchange survey, but researchers gave patients at the University of Cincinnati Endocrinology Clinic pre-visit questionnaires that included the question. Here, 51% of 207 CGM users who responded reported at least one gap in the past 3 months, with an average duration of 16.5 days. The top reason reported was early CGM failure.
For insulin pumps, 16.5% of 109 respondents reported at least one gap in the past month, with an average duration of 19.2 days.
To inform his call for insurers to cover extra diabetes supplies, Welch presented published study data from the manufacturers of marketed CGMs. Reported early failure rates ranged from 13% to 23%. Using this data, he estimated the number of sensors that fail early per year ranges from 3.2 to 7.6, depending on the manufacturer.
'If we know that this is happening, and even the studies that led to the approval show this, why is it so hard to get extras, and why are we always on the edge of running out, and why can't we make this better? That's my call to action,' he concluded.
Welch reported no relevant financial relationships. Ahn is a speaker for, advisor for, and/or recipient of research grants from Abbott, Ascensia, Insulet, Lilly, MannKind, Novo Nordisk, Xeris, Sequel, Lilly, Honey Health, Medtronic, and Tandem.