Inequity in access to continuous glucose monitoring and health outcomes in paediatric diabetes, a case for national continuous glucose monitoring funding: A cross-sectional population study of children with type 1 diabetes in New Zealand

Abstract

Background: Continuous glucose monitoring (CGM) improves glycaemia for people affected by type 1 diabetes (T1D), but is not funded in Aotearoa/New Zealand. This study explores the impact of non-funded CGM on equity of access and associated glycaemic outcomes.

Methods: Cross-sectional population-based study collected socio-demographic (age, gender, prioritised ethnicity, socioeconomic status) and clinical data from all regional diabetes centres in New Zealand with children <15 years with T1D as of 1st October 2021. De-identified data were obtained from existing databases or chart review. Outcomes compared socio-demographic characteristics between those using all forms of CGM and self-monitoring of blood glucose (SMBG), and association with HbA1c.

Findings: 1209 eligible children were evaluated: 70.2% European, 18.1% Māori, 7.1% Pacific, 4.6% Asian, with even distribution across socioeconomic quintiles. Median HbA1c was 64 mmol/mol (8.0%), 40.2% utilised intermittently scanned (is)CGM, and 27.2% real-time (rt)CGM. CGM utilisation was lowest with Pacific ethnicity (38% lower than Māori) and the most deprived socioeconomic quintiles (quintile 5 vs. 1 adjusted RR 0.69; 95% CI, 0.57 to 0.84). CGM use was associated with regional diabetes centre (P < 0.001). The impact of CGM use on HbA1c differed by ethnicity: Māori children had the greatest difference in HbA1c between SMBG and rtCGM (adjusted difference -15.3 mmol/mol; 95% CI, -21.5 to -9.1), with less pronounced differences seen with other ethnicities.

Interpretation: Inequities in CGM use exist based on prioritised ethnicity and socioeconomic status. Importantly, CGM was independently associated with lower HbA1c, suggesting that lack of CGM funding contributes to health disparity in children with T1D.

Funding: Australasian Paediatric Endocrine Group (APEG), Canterbury Medical Research Foundation, Starship Foundation.

Keywords: Continuous glucose monitoring; Diabetes technology; Disparity; Equity; Paediatrics; Type 1 diabetes.

Fig. 1

Percent of children using glucose monitoring modality by ethnicity and socioeconomic deprivation. Point range plots showing unadjusted percentages (95% binomial confidence intervals) of children <15 years with T1D according to glucose monitoring modality (rows), prioritised ethnicity (columns), and New Zealand Deprivation (NZDep) quintile where quintile 1 is the least deprived and quintile 5 is the most deprived. SMBG is self-monitoring of blood glucose, isCGM is intermittently scanned CGM, and rtCGM is real-time CGM. Dashed horizontal lines represent overall means for each ethnicity.

Fig. 2

HbA1c by ethnicity, stratified by CGM use. Point range plots showing the estimated mean HbA1c (mmol/mol) of children with type 1 diabetes in New Zealand, according to their ethnicity and continuous glucose monitoring (CGM) use. SMBG is self-monitoring of blood glucose, isCGM is intermittently scanned CGM, and rtCGM is real-time CGM. Black dots with grey bands represent estimated mean HbA1c with 95% confidence intervals. Within each panel, pairwise comparisons of groups with confidence intervals that do not overlap may be considered to differ with P < 0·05.