Comparison of Socioeconomic Disparities in Pump Uptake Among Children With Type 1 Diabetes in 2 Canadian Provinces With Different Payment Models

IMPORTANCE Insulin pumps improve glycemic control and quality of life in children with type 1 diabetes (T1D). Canada's provinces have implemented universal pediatric programs to improve access. However, these programs provide differing financial coverage, allowing for unique cross-jurisdictional comparisons. OBJECTIVE To evaluate possible socioeconomic status (SES) disparities in pump uptake in Quebec, where pumps are fully funded, with those in Manitoba, where pumps are partially funded. DESIGN, SETTING, AND PARTICIPANTS Using health administrative databases and a clinical registry, parallel, population-based cohort studies of children with diabetes were conducted from April I, 2011, in Quebec, and April 1, 2012, in Manitoba, until March 31, 2017. In analysis conducted from July 1. 2019, to November 30, 2021, multivariable Cox proportional hazards regression models were applied to study the association between pump uptake and SES, defined using validated area-based material and social deprivation indices. Children aged 1 to 17 years with T1D were identified using a validated definition in administrative data (Quebec) and a clinical registry (Manitoba). Those using pumps before the initiation of provincial programs were excluded. EXPOSURES Socioeconomic status. MAIN OUTCOMES AND MEASURES Insulin pump uptake. RESULTS A total of 2919 children with T1D were identified in Quebec: 1550 male (53.1%), mean (SD) age at diagnosis, 8.3 (4.4) years, and 1067 (36.6%) were using a pump. In Manitoba, 636 children were identified: 364 male (57.2%), mean (SD) age at diagnosis, 8.8 (4.4) years, and 106 (16.7%) were using a pump. In Quebec, the mean age at diagnosis of T1D was lower in children using the pump compared with those not using a pump (7.6 [4.1] vs 8.7 [4.5] years); sex distribution was similar (562 [52.7%] vs 988 [53.3%] male). No differences in mean (SD) age at diagnosis (8.8 [4.4] vs 8.8 [4.3] years) or sex (57 [53.8%] vs 307 [57.9%] male) were noted in both groups in Manitoba. Increasing material deprivation was associated with decreased pump uptake in both Quebec (adjusted hazard ratio [aHR] 0.89; 95% CI, 0.85-0.93) and Manitoba (aHR, 0.70; 95% CI, 0.60-0.82). Inclusion of ethnic concentration did not change this association. Socioeconomic disparities in pump uptake were greater in Manitoba than Quebec (P = .006 by t test; Cochran Q, 8.15; P = .004; I-2 = 87.7%; 95% CI, 52.5%-96.8%). CONCLUSIONS AND RELEVANCE The results of this study suggest that the program of full coverage for pumps available in Quebec partially mitigates observed SES disparities in uptake and may be a model to improve access for all children with T1D.

Automated summary

This study compares socioeconomic status (SES) disparities in insulin pump uptake in children with type 1 diabetes (T1D) in Quebec (fully funded pumps) and Manitoba (partially funded pumps). Results suggest that full coverage programs in Quebec partially mitigate SES disparities in uptake and may serve as a model to improve access for all children with T1D.