ESPE Yearbook of Paediatric Endocrinology

To read the full abstract: Pediatr Diabetes. 2020 Mar;21(2):319–327. doi: 10.1111/pedi.12971. Epub 2020 Jan 3. PMID: 31885123

Dissatisfaction with technologies, discontinuation of use and inappropriate adjustments of insulin pump settings pose important areas of concern in adolescents using diabetes technologies. This study searched for predictors of hybrid closed loop (HCL) discontinuation and perceived barriers to use in 92 adolescents with type 1 diabetes (T1DM) (age 8–25 years) who had initiated the Minimed 670G HCL system. Participants were followed prospectively for only 6 months and data collected on demographic, glycemic (time-in-range, HbA1c), and psychosocial variables [Hypoglycemia Fear Survey (HFS); and Problem Areas in Diabetes (PAID)]. In addition and importantly, participants who discontinued HCL (<10% HCL use at clinical visit) completed a questionnaire on perceived barriers to HCL use.

Ninety-two participants (15.7 ± 3.6 y, HbA1c 8.8 ± 1.3%, 50% female) initiated HCL, and 28 (30%) discontinued it, the majority (64%) after 3–6 months. Odds of discontinuing HCL was 2.7-fold higher (95% CI: 1.12, 6.28; P =0.026) for each 1% higher baseline HbA1c. Youth who discontinued HCL rated difficulty with calibrations, number of alarms, and too much time needed to make the system work as the biggest problems of HCL. Qualitatively derived themes included technological difficulties (error alerts, not working correctly), too much work (calibrations, finger sticks), alarms, disappointment in glycemic control, and expense (cited by parents).

Youth with higher baseline HbA1c are at higher risk of discontinuing HCL within 6 months and should be the target of new interventions to support device use. The primary reasons for discontinuing HCL relate to the workload required to use HCL. This echoes evidence from an obesity intervention trial where the major reason for non-participation was lack of time, cumbersomeness and effort to attend the program (1).

HCL systems were implemented to improve the time in glucose target range in T1DM patients and to possibly make care easier especially in younger patients. There is evidence that, even in patients with poor metabolic control, such systems can improve time in range. However, with the 670G system the workload will increase (at least for the first months) for a patient transferring from the 640G or other insulin pumps due to need for multiple calibration finger sticks. On the other hand, parents and patients will have to let the system control the child. This in itself is not always easy and may represent an additional psychologic barrier to use. These authors described their intensive efforts at patient education after initiation of HCL. Those patients who discontinued had worse metabolic control and reported using the system and CGM significantly less already in the first month. They disliked the workload due to extra blood glucose measurements and attending to alarms. It is recommended that diabetes teams should develop a system to better identify patients/families who will possibly find HCL to burdensome and focus on education before starting to discuss the use of HCL. Such education should include the potential workload involved and possible problems compared to more traditional treatments. The 670G is the first available HCL system and upcoming systems should be improved regarding ease of calibration and kicking off on auto mode.

Reference:

1. Alff F, Markert J, Zschaler S, Gausche R, Kiess W, Blüher S. Reasons for (non)participating in a telephone-based intervention program for families with overweight children. PLoS One. 2012;7(4):e34580. doi: 10.1371/journal.pone. 0034580. Epub 2012 Apr 3