Impact of removing restrictive haemoglobin A1C eligibility criteria for insulin pump therapy funding for children with type 1 diabetes in Ontario, Canada

Aims — In Ontario, publicly funded insulin pump therapy has been available to children with Type 1 diabetes since 2006. Before 31 March 2022, eligibility required three Haemoglobin A1c (A1C) measurements in the preceding year, with the two most recent < 10%. On 1 April 2022, this criterion was removed. We assessed whether this policy change reduced socioeconomic disparities in pump access among new applicants.

Materials and methods — We conducted a population-based retrospective cohort study including all children in Ontario who applied for insulin pump funding from program inception to 31 March 2024. The primary exposure was the time period (pre- vs. post-policy change). The outcome was social disadvantage, measured using a five-level neighbourhood index. Ordinal logistic regression with generalised estimating equations (accounting for neighbourhood clustering) estimated the odds of greater disadvantage post-policy, adjusting for age, sex and diabetes duration. Segmented regression assessed changes over time in differences in application proportions between the most and least disadvantaged quintiles.

Results — A total of 7540 children applied pre-policy and 1311 post-policy. The mean A1C at application was similar between time periods (8.5% vs. 8.3%, p = 0.0002). Adjusted odds of greater disadvantage were higher post-policy (OR: 1.32, 95% CI: 1.18–1.47). The difference in applications between the most versus least disadvantaged quintile decreased by 0.13%/quarter (95% CI: −0.22 to −0.05) pre-policy and by 1.64%/quarter (95% CI: −8.3 to 5.0) post-policy, though the pre versus post-policy difference was not statistically significant (p = 0.1).

Conclusions — Removal of A1C-based eligibility may improve equity in paediatric insulin pump access, though longer follow-up is needed.