Exposure to diabetes technologies: Where now for adult services?
Access to self-management and monitoring technologies for children with diabetes has improved considerably in recent years. This has been aided by improvements in technologies and their availability, and in healthcare delivery. An important contributor to the availability of diabetes technologies in England is the Best Practice Tariff for pediatric diabetes, which was introduced in 2012–2013 (and updated in 2017) as a mandated payment system applied to pediatric diabetes services in England and Wales.
What is the Best Practice Tariff for pediatric diabetes?
The Best Practice Tariff sets the standard of care required for every young person with diabetes under 19 years of age who attends a pediatric diabetes clinic. For context, at the time of the Best Practice Tariff’s launch, data from the 2011–2012 National Paediatric Diabetes Audit suggested that only 6.7% of children and young people with diabetes over the age of 12 years had all of their care processes recorded.
The Best Practice Tariff payment was set at a level intended to improve access to technology and promote consistent, high quality management of their diabetes, regardless of where it is delivered to children and adolescents. The guidelines underpinning the Best Practice Tariff include the following:
UK Department of Health
UK National Health Service
Device access, uptake and support
While access to technologies for adults with diabetes has improved, it has been to a lesser extent than in the pediatric setting. Efforts to improve device uptake among adults are ongoing, and include the recent National Health Service (NHS) England initiative to provide access to flash glucose monitoring for all eligible adults with type 1 diabetes. Although this program was met with a mixed response initially, current indications are that access is improving. Nonetheless, more time is needed to determine whether greater access will result in better glycemic control and outcomes for users.
Despite the spotlight on access, it will be interesting to see what level of support adult users receive to meet their individual needs. Technologies in themselves are insufficient to improve diabetes control (glycemic or psychosocial) and can add to the burden of diabetes if they are not introduced with appropriate tailored support to meet the individual needs of the users.
The picture with insulin pump therapy
Insulin pump uptake amongst adults with diabetes remains low, with the 2016–2017 National Diabetes Insulin Pump Audit stating that:
the ten fold variation between specialist centres in pump use by people with type 1 diabetes suggests a lack of access for patients attending some services and should be investigated.
Pump treatment is more often seen among younger people with type 1 diabetes, with 25.9% of those under 30 years of age using the treatment compared with only 8.9% of those aged 60–69 years. There is also a clear decrease in the number of people using pumps in line with increasing levels of deprivation, with only 15% of pump use occurring in those most deprived compared with 24% in those least deprived. These figures are mirrored in pediatric services, with 25.6% of those most deprived using pump therapy compared with 37.5% of those least deprived.
There are a number of quality of life and glycemic benefits associated with insulin pump therapy. So it is somewhat disappointing that pump uptake in people with type 1 diabetes currently remains flat, at 15.6% in England and 6.7% in Wales (32.4% of children use pumps in England and Wales, 45.7% of 0–4 year olds), compared with 15.3% and 5.8% respectively in 2015–2016. Additional data from the National Diabetes Insulin Pump Audit suggest that 90% of adults using pumps reach target goals for hypoglycemia, and those individuals using pumps are more likely to achieve their treatment targets for glycated hemoglobin (HbA1c), blood pressure, and cholesterol than those without pumps (20.3 vs 16.4%). However, the reality remains that this represents a minority of people with diabetes.
Cutting through the confusion?
“In both adults and children with diabetes, technologies such as continuous subcutaneous insulin infusion using insulin pumps and continuous glucose monitoring can help improve diabetes control, reduce hypoglycaemia and improve quality of life”.
This is true, yet access remains varied at best. The consensus paper goes on to suggest that:
“Different guidelines for adults and children further complicate access to diabetes technology in the transition from paediatric to adult care”.
The consensus paper, it is argued,
“[combines] the different technologies into a common pathway to aid clinical and policy decision-making […] the pathway emphasizes the importance of structured education, specialist support and appropriate access to psychological therapies, as essential pillars for optimized use of diabetes-related technology, and recommends the re-evaluation of its use when the individual is unable either to use the technology appropriately or to achieve the intended outcomes”.
What is less clear, however, is whether the “intended outcomes” include psychosocial benefits and who will provide psychological support in adult services where availability is currently lacking.
Pediatric diabetes care in England and Wales: Blazing the trail
In contrast to the situation in adult care, pediatric services appear to be ahead of the curve. The 2016–2017 National Paediatric Diabetes Audit Report conducted in England and Wales showed that diabetes management has improved for the seventh consecutive year, with increasing numbers of children and adolescents with type 1 diabetes regarded as achieving “excellent” control. To present this in context, between 2011 and 2012 only 17.4% of children and young people with diabetes had an HbA1c of <58 mmol/mol (<7.5%) as compared with 28.9% between 2016 and 2017. While there remains some way to go in terms of the proportion of children reaching the optimal target, consistent improvements year-on-year are promising, particularly when considered alongside the reducing numbers of children with HbA1c results of >80 mmol/mol (>9.5%) from 25.1% in 2011–2012 down to 16.4% in 2016–2017. It is my opinion that the standard of pediatric diabetes care and adoption of technologies are key factors in the achievement of this improvement.
Why a little support goes a long way
Almost three-quarters of children and adolescents with type 1 diabetes (74.1%) received a psychological assessment in 2016–2017. Of these, 34.0% required referral and were seen by expert (child and adolescent mental health services [CAMHS]) or psychology services for emotional wellbeing support. Over a third (37.4%) of those with type 2 diabetes required referral to CAMHS or psychology services for emotional wellbeing support (61.3% received a psychological assessment, falling short of the figures for type 1 diabetes). Increasingly, diabetes services are including dedicated psychologists within their multi-disciplinary teams, ensuring that children are able to routinely speak with a psychologist when they attend the diabetes clinic for regular appointments, as well as being able to make additional appointments as required. Where a dedicated diabetes psychologist is not part of the multi-disciplinary team, there are clear links to CAMHS.
So, where now for adult services?
Children have a habit of growing up! And, as they do, responsibility for their care will shift to adult services. In making this transition, I believe that these individuals will expect their standard of care to at least match what it was within the pediatric service. As things stand currently, this expectation will be unmet. However, the work that is being done to improve pathways for diabetes technologies, and to introduce psychological support across adult services, promises to ensure that it should not be long before adult services are able to match the care provided under the Best Practice Tariff in pediatric services.