Global Inequities in Diabetes Technology and Insulin Access and Glycemic Outcomes

Abstract

Importance: Advanced diabetes technologies such as continuous glucose monitoring (CGM), continuous subcutaneous insulin infusion (insulin pumps [CSII]), and glucometers alongside insulin access represent the criterion standard for managing type 1 diabetes (T1D) in children. Global disparities in their access and reimbursement may be associated with glycemic outcomes.

Objective: To describe how accessibility and reimbursement of advanced diabetes technologies and insulin are associated with glycated hemoglobin (HbA1c) levels in centers participating in the SWEET initiative, an international pediatric diabetes registry.

Design, setting, and participants: This global multicenter cross-sectional study collected data from 81 centers in 56 countries. Web-based questionnaires were distributed to representatives of all 121 pediatric diabetes centers participating in the SWEET initiative from March 1 to May 31, 2024, and used to map accessibility of and reimbursement for CGM, CSII, glucometers, and insulin. Reimbursement data were compared with HbA1c levels using the SWEET Study dataset. Participants included 42 349 children with T1D.

Exposures: Responses were categorized into 4 groups based on the extent of reimbursement for diabetes technologies and insulin.

Main outcomes and measures: Mean HbA1c levels across centers calculated from measurements current as of December 31, 2023, analyzed by categories of accessibility of and reimbursement for diabetes technologies and insulin.

Results: Data collected from 81 of 121 SWEET centers (67%) across 56 countries included HbA1c levels from 42 349 children with T1D (22 021 male [52%]; mean [SD] age, 14.3 [4.4] years; mean [SD] diabetes duration, 6.0 [4.2] years). Universal access with complete reimbursement for all technologies and insulin was reported by 32 centers from 19 countries, while 8 countries reported no reimbursement for any technologies or insulin. Centers with full reimbursement for CSII, CGM, glucometers, and insulin showed mean HbA1c levels of 7.62% (95% CI, 7.59%-7.64%) to 7.75% (95% CI, 7.73%-7.77%) compared with 9.65% (95% CI, 9.55%-9.71%) to 10.49% (95% CI, 10.40%-10.58%) in centers with no reimbursement and/or no availability (P < .001 for all items).

Conclusions and relevance: This cross-sectional study found that HbA1c levels were associated with the accessibility of modern diabetes technologies and insulin. Efforts to ensure universal accessibility are required to reduce global inequities and glycemic outcomes for children with T1D.

Figure 1.. The Accessibility of and Reimbursement Type for Diabetes Technology in Different Countries

Created with MapChart, version 6.7.1, April 29, 2025.

Figure 2.. Glycated Hemoglobin (HbA_1c) Level by Type of Reimbursement for Diabetes Technology

HbA_1c levels are presented as means; whiskers represent 95% CIs. The lowest HbA_1c level was reached by children with type 1 diabetes treated in centers with full reimbursement of all the technologies. The differences between the types of reimbursement are statistically significant for all technologies (P < .001).

Figure 3.. The Distribution of Individual Centers From Different Continents by Glycated Hemoglobin (HbA_1c) Value and Type of Reimbursement

Bubble size reflects the number of centers that fall into the same HbA_1c range (within 1%) and reimbursement category within a specific continent. The smallest bubble size represents a center that is alone in its category, whereas the largest bubble size indicates that more than 10 centers share the same category.