Timing of insulin pump initiation among individuals with type 1 diabetes in Ontario, Canada

Aims — To assess characteristics associated with earlier (≤2 years since diagnosis) versus later (>2 years) insulin pump initiation among new type 1 diabetes applicants to the publicly funded insulin pump program in Ontario, and whether timing of pump initiation is associated with cumulative glycaemic exposure.

Materials and methods — A retrospective population-based cohort study was conducted using administrative healthcare databases in Ontario, Canada. All pump program applicants prior to 31 March 2021 were included. An adjusted log-binomial regression model using generalized estimating equations assessed associations between patient- and physician-level characteristics and earlier versus later pump initiation. A linear regression model examined differences in cumulative HbA1c over time between earlier versus later pump initiators.

Results — Among 4899 individuals, 62.6% were earlier pump initiators. Greater social disadvantage was associated with lower likelihood of earlier pump initiation [adjusted relative risk (RR) 0.81 (95% confidence interval {CI} 0.75–0.88)] for most versus least disadvantaged quintile. Compared to paediatrician care, endocrinologist [RR 0.85 (95% CI 0.79, 0.91)], general internist [0.73 (0.64–0.83)], and family physician care [0.28 (0.21–0.37)] were associated with less earlier pump initiation. Older age at diagnosis and physician training prior to publicly funded pump therapy were associated with less earlier pump initiation. Earlier pump initiators had a significantly lower annual rate of increase in cumulative HbA1c compared with later initiators (−0.33% per year; 95% CI −0.45 to −0.20; p < 0.001), although cumulative HbA1c at 10 years did not differ significantly between groups (mean difference −1.50; p = 0.112).

Conclusions — Social disadvantage and physician characteristics are associated with less earlier pump initiation, which may have negative long-term effects on glycaemic management. Barriers to earlier pump initiation should be removed to promote equitable access and optimize glycaemic outcomes.