Social disadvantage and technology use among adults with type 1 diabetes in Quebec: A cross‐sectional study using data from the Canadian T1D ( BETTER ) Registry

Disparities in diabetes technology use persist despite the availability of insurance or public funding.

“Although financial costs are a major barrier to accessing diabetes technologies, disparities persist despite the availability of insurance or public funding.”

• cites [20] Agarwal S, Schechter C, Gonzalez J, Long JA. Racial‐ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther. 2021; 23(4): 306‐ 313. 33155826 PMC7994432 sourceSupported
• cites [23] Addala A, Auzanneau M, Miller K, et al. A decade of disparities in diabetes technology use and HbA1c in pediatric type 1 diabetes: a transatlantic comparison. Diabetes Care. 2021; 44(1): 133‐ 140. 32938745 PMC8162452 sourceSupported
• cites [25] Khanolkar AR, Amin R, Taylor‐Robinson D, Viner RM, Warner JT, Stephenson T. Young people with type 1 diabetes of non‐white ethnicity and lower socio‐economic status have poorer glycaemic control in England and Wales. Diabet Med. 2016; 33(11): 1508‐ 1515. 26802317 sourceCould not verify

  The available Introduction reports ethnic and socioeconomic disparities in glycaemic control, not diabetes technology use. Searches for insulin pumps, technology access, insurance, and public funding found no passage establishing that technology-use disparities persist despite coverage. The indexed text is also headed as a different paper that cites the named source, so it cannot verify this attribution. (LLM, conf=0.76)

  Experimental — accuracy not yet measured

Inequitable use of diabetes technologies contributes at least in part to worse diabetes outcomes for socially disadvantaged groups with T1D.

“Inequitable use of diabetes technologies contributes at least in part to worse diabetes outcomes for socially disadvantaged groups with T1D (e.g., racial or ethnic minority or lower socioeconomic status [SES]).”

• cites [23] Addala A, Auzanneau M, Miller K, et al. A decade of disparities in diabetes technology use and HbA1c in pediatric type 1 diabetes: a transatlantic comparison. Diabetes Care. 2021; 44(1): 133‐ 140. 32938745 PMC8162452 sourcePartly supported

  The Conclusions report that technology use was lowest and HbA1c highest among youth in the lowest SES quintile in the U.S. But they explicitly say causal conclusions cannot be drawn, so the paper does not establish that inequitable technology use contributes to worse outcomes. The Introduction also reports lower technology use and higher HbA1c among pediatric patients of minority status, without establishing that causal link. (LLM, conf=0.89)

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• cites [24] Agarwal S, Kanapka LG, Raymond JK, et al. Racial‐ethnic inequity in Young adults with type 1 diabetes. J Clin Endocrinol Metabol. 2020; 105(8): e2960‐ e2969. PMC7457963 32382736 sourcePartly supported

  The Discussion (page not provided) says lower diabetes technology use contributed to the remaining Black–White disparity in glycemic control after adjustment for socioeconomic status. The study concerns young adults, however, and does not establish the same contribution across all people with T1D or independently for lower-SES groups. (LLM, conf=0.84)

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Insulin pumps and CGM are less commonly used among groups who identify as racial or ethnic minorities, even after adjustment for socioeconomic and clinical factors.

“Insulin pumps and CGM are less commonly used among groups who identify as racial or ethnic minorities, even after adjustment for socioeconomic factors such as income and insurance status, and clinical factors such as healthcare utilization and diabetes self‐management.”

• cites [20] Agarwal S, Schechter C, Gonzalez J, Long JA. Racial‐ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther. 2021; 23(4): 306‐ 313. 33155826 PMC7994432 sourcePartly supported

  The Results and Table 2 report lower adjusted pump and CGM use for non-Hispanic Black than White young adults with type 1 diabetes. The claim overgeneralizes to all racial or ethnic minority groups: after adjustment, Hispanic participants had higher CGM use than White participants (58% versus 53%). Table 2 lists insurance and other socioeconomic measures among the adjustment factors, but not household income itself. (LLM, conf=0.88)

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• cites [21] Fantasia KL, Wirunsawanya K, Lee C, Rizo I. Racial disparities in diabetes technology use and outcomes in type 1 diabetes in a safety‐net hospital. J Diabetes Sci Technol. 2021; 15(5): 1010‐ 1017. 33719610 PMC8442173 sourceNot checked — no full text of the source
• cites [22] Lai CW, Lipman TH, Willi SM, Hawkes CP. Racial and ethnic disparities in rates of continuous glucose monitor initiation and continued use in children with type 1 diabetes. Diabetes Care. 2021; 44(1): 255‐ 257. 33177169 sourceNot checked — no full text of the source

Socially disadvantaged groups may have greater absolute benefit from initiating diabetes technologies given their higher HbA1c.

“However, socially disadvantaged groups may in fact have greater absolute benefit from initiating these technologies 39 , 40 given their higher HbA1c, and should be prioritised for AID.”

• cites [39] Boucsein A, Watson AS, Frewen CM, et al. Impact of advanced hybrid closed loop on youth with high‐risk type 1 diabetes using multiple daily injections. Diabetes Care. 2023; 46(3): 628‐ 632. 36689621 sourceNot checked — no full text of the source
• cites [40] Botros S, Islam N, Hursh B. Insulin pump therapy, pre‐pump hemoglobin A1c and metabolic improvement in children with type 1 diabetes at a tertiary Canadian children's hospital. Pediatr Diabetes. 2019; 20(4): 427‐ 433. 30779269 sourcePartly supported

  The Discussion reports that children with higher pre-pump HbA1c had greater HbA1c improvement after starting insulin pump therapy, supporting the possibility of greater absolute benefit for people with higher baseline HbA1c. But the study did not assess whether socially disadvantaged groups had higher HbA1c or greater benefit; its Limitations explicitly say socioeconomic status could not be addressed. It studied insulin pumps, not AID specifically. Page numbers were not available in our copy. (LLM, conf=0.88)

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Within two years after the introduction of public funding of CGM in Australia for youth with T1D, 79% used CGM.

“Within two years after the introduction of public funding of CGM in Australia for youth with T1D, 79% used CGM, a similar proportion as in our results.”

• cites [35] Johnson S, Holmes‐Walker D, Chee M, Earnest A, Jones T. Universal subsidized continuous glucose monitoring funding for Young people with type 1 diabetes: uptake and outcomes over 2 years, a population‐based study. Diabetes Care. 2021; 45: dc211666. PMC8914416 34872983 sourceSupported

Prior studies demonstrate prominent socioeconomic disparities in insulin pump use in regions without public funding, such as Brazil and the United States.

“Our findings of greater disparities in insulin pump use are consistent with prior studies demonstrating prominent socioeconomic disparities in regions without public funding, such as Brazil and the United States.”

• cites [36] Gomes MB, Rodacki M, Pavin EJ, et al. The impact of ethnicity, educational and economic status on the prescription of insulin therapeutic regimens and on glycemic control in patients with type 1 diabetes. A nationwide study in Brazil. Diabetes Res Clin Pract. 2017; 134: 44‐ 52. 28951342 sourceNot checked — no full text of the source
• cites [37] DeSalvo DJ, Noor N, Xie C, et al. Patient demographics and clinical outcomes among type 1 diabetes patients using continuous glucose monitors: data from T1D exchange real‐world observational study. J Diabetes Sci Technol. 2021; 17(2): 322‐ 328. 34632823 PMC10012384 sourcePartly supported

  The Discussion (page not provided) says socioeconomic status and insurance coverage can affect insulin pump and CGM use because of financial constraints. However, this study measures CGM use in U.S. clinics, not insulin pump disparities; it does not address Brazil or establish that either region lacks public funding. (LLM, conf=0.86)

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Previous studies demonstrate glycaemic benefits for CGM and insulin pump.

“HbA1c was lower among CGM and insulin pump users in the BETTER Registry, which is consistent with previous studies demonstrating glycaemic benefits for these technologies.”

• cites [1] Roze S, Smith‐Palmer J, Valentine W, de Portu S, Nørgaard K, Pickup JC. Cost‐effectiveness of continuous subcutaneous insulin infusion versus multiple daily injections of insulin in type 1 diabetes: a systematic review. Diabet Med. 2015; 32(11): 1415‐ 1424. 25962621 sourceNot checked — no full text of the source
• cites [3] Oyagüez I, Merino‐Torres JF, Brito M, et al. Cost analysis of the flash monitoring system (FreeStyle libre 2) in adults with type 1 diabetes mellitus. BMJ Open Diabetes Res Care. 2020; 8(1): e001330. PMC7375427 32699114 sourcePartly supported

  The Introduction reports that a trial found fewer hypoglycaemic episodes with flash glucose monitoring, supporting a glycaemic benefit for that technology. The paper does not report a glycaemic benefit for insulin pumps, and the Research design and methods table gives baseline HbA1c rather than an HbA1c reduction. Neither passage has a page number in our copy. (LLM, conf=0.87)

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• cites [5] Weisman A, Bai JW, Cardinez M, Kramer CK, Perkins BA. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta‐analysis of outpatient randomised controlled trials. Lancet Diabetes Endocrinol. 2017; 5(7): 501‐ 512. 28533136 sourceNot checked — no full text of the source

Clinical practice guidelines are increasingly recommending AID systems, which require both CGM and insulin pumps, as the standard of care for individuals with T1D.

“Clinical practice guidelines are increasingly recommending automated insulin delivery (AID) systems, which require both CGM and insulin pumps, as the standard of care for individuals with T1D.”

• cites [7] Sherr JL, Schoelwer M, Dos Santos TJ, et al. ISPAD clinical practice consensus guidelines 2022: diabetes technologies: insulin delivery. Pediatr Diabetes. 2022; 23(8): 1406‐ 1431. doi: 10.1111/pedi.13421 36468192 sourcePartly supported

  Section 9.1 (page not available) states that AID systems consist of an insulin pump and a CGM sensor, and section 9 strongly recommends AID for children with diabetes. The guideline does not establish AID as the standard of care for all individuals with T1D or document a trend across guidelines toward that designation. (LLM, conf=0.87)

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• cites [41] Halperin IJ, Wicklow B, Amed S, et al. Glycemic management across the lifespan for people with type 1 diabetes: a clinical practice guideline. Can J Diabetes. 2025; 49(1): 5‐ 18. 40155190 sourceSupported

Previous studies have demonstrated associations between income, insurance status and Race on use of diabetes technologies.

“Although previous studies have demonstrated associations between income, insurance status and Race on use of diabetes technologies, 21 , 23 , 24 we are not aware of any previous studies applying an intersectional approach.”

• cites [21] Fantasia KL, Wirunsawanya K, Lee C, Rizo I. Racial disparities in diabetes technology use and outcomes in type 1 diabetes in a safety‐net hospital. J Diabetes Sci Technol. 2021; 15(5): 1010‐ 1017. 33719610 PMC8442173 sourceNot checked — no full text of the source
• cites [23] Addala A, Auzanneau M, Miller K, et al. A decade of disparities in diabetes technology use and HbA1c in pediatric type 1 diabetes: a transatlantic comparison. Diabetes Care. 2021; 44(1): 133‐ 140. 32938745 PMC8162452 sourceSupported
• cites [24] Agarwal S, Kanapka LG, Raymond JK, et al. Racial‐ethnic inequity in Young adults with type 1 diabetes. J Clin Endocrinol Metabol. 2020; 105(8): e2960‐ e2969. PMC7457963 32382736 sourcePartly supported

  The Results (Racial-ethnic comparisons; page unavailable) show substantially lower insulin-pump and CGM use among Black and Hispanic young adults than among White young adults, supporting the race-related association. The paper also reports differences in income and insurance by racial-ethnic group, but it does not establish separate associations of income or insurance status with technology use; the Discussion notes that technology-use disparities persisted despite device coverage. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Insulin pump use was associated with more individual social disadvantage variables than CGM use.

“Insulin pump use was associated with more individual social disadvantage variables than CGM use.”

Insulin pump use is not associated with severe hypoglycaemia (OR 0.77, 95% CI 0.56-1.06).

“In contrast, insulin pump use was not associated with severe hypoglycaemia or any diabetes hospitalization (OR 0.77 [95% CI 0.56–1.06] and 1.08 [95% CI 0.64–1.81, respectively]; Table 4).”

Odds of CGM use decrease successively with an increasing number of social disadvantage indicators.

“A gradient was observed with successively lower odds of using both an insulin pump and CGM as the number of social disadvantage indicators increased (Table 2).”

Among 2380 adults with T1D in Quebec, 82.5% used CGM.

“Among 2380 adults with T1D, 37.4% used insulin pumps and 82.5% used CGM.”

Prevalence across intersections ranged from 0.73 to 0.86 for CGM use.

“Less variability across social disadvantage variables was observed for CGM than for the insulin pump, with prevalence across intersections ranging from 0.16 to 0.47 for insulin pump use and 0.73 to 0.86 for CGM use.”

Insulin pump use is not associated with diabetes hospitalization (OR 1.08, 95% CI 0.64-1.81).

“In contrast, insulin pump use was not associated with severe hypoglycaemia or any diabetes hospitalization (OR 0.77 [95% CI 0.56–1.06] and 1.08 [95% CI 0.64–1.81, respectively]; Table 4).”

Less variability across social disadvantage variables was observed for CGM than for insulin pump.

“Less variability across social disadvantage variables was observed for CGM than for the insulin pump, with prevalence across intersections ranging from 0.16 to 0.47 for insulin pump use and 0.73 to 0.86 for CGM use.”

CGM use is not associated with severe hypoglycaemia (OR 1.11, 95% CI 0.76-1.63).

“CGM use was associated with lower odds of being in a higher HbA1c category (OR 0.74 [95% CI 0.58–0.96] for being in any higher HbA1c category), but not severe hypoglycaemia or any diabetes hospitalization (OR 1.11 [95% CI 0.76–1.63] and 1.05 [95% CI 0.59–1.87], respectively).”

Prevalence of insulin pump and CGM was highest among participants who were White and had private insurance.

“The prevalence of insulin pump and CGM was highest among participants who were White and had private insurance, and similar between the other remaining intersections.”

The final sample included 2380 participants (2149 with T1D and 231 with LADA using insulin).

“Our final sample included 2380 participants (2149 with T1D and 231 with LADA using insulin).”

Non-White Race is associated with higher odds of severe hypoglycaemia.

“Income <$80 000, non‐White Race and unemployment were associated with higher odds of severe hypoglycaemia, whereas only income <$80 000 was associated with higher odds of any diabetes hospitalization (Table 4).”

Individuals with five or more social disadvantage indicators had 67% lower odds of CGM use after adjusting for age and diabetes duration (OR 0.33, 95% CI 0.18-0.59).

“Individuals with five or more social disadvantage indicators had 81% lower odds of insulin pump use after adjusting for age and diabetes duration (OR 0.19 [95% CI 0.10–0.37]) and 67% lower odds of CGM use (OR 0.33 [95% CI 0.18–0.59]).”

Individuals with five or more social disadvantage indicators had 81% lower odds of insulin pump use after adjusting for age and diabetes duration (OR 0.19, 95% CI 0.10-0.37).

“Individuals with five or more social disadvantage indicators had 81% lower odds of insulin pump use after adjusting for age and diabetes duration (OR 0.19 [95% CI 0.10–0.37]) and 67% lower odds of CGM use (OR 0.33 [95% CI 0.18–0.59]).”

Public insurance is associated with lower odds of insulin pump use (adjusted OR 0.47, 95% CI 0.35-0.62).

“Annual household income <$80 000 (adjusted OR 0.64 [0.50–0.82]), no post‐secondary education (adjusted OR 0.62 [0.46–0.85]), non‐White Race (adjusted OR 0.47 [0.30–0.73]) and public insurance (adjusted OR 0.47 [0.35–0.62]) were associated with lower odds of insulin pump use after adjustment for potential confounders (Table 2).”

Models including an interaction between insulin pump or CGM use and social disadvantage variables did not improve model fit, indicating no meaningful interactions.

“Models that included an interaction between use of insulin pump or CGM and social disadvantage variables did not improve model fit, indicating no meaningful interactions.”

In this cross-sectional analysis of 2380 adults with T1D in Quebec participating in the BETTER Registry, social disadvantage was associated with lower utilization of insulin pumps and CGM.

“In summary, social disadvantage is associated with lower uptake of both CGM and insulin pump among adults with T1D in Quebec, though public funding possibly partially mitigates disparities in CGM use.”

Among both socially advantaged and disadvantaged participants, the majority with an HbA1c ≤7.0% or 7.1%-8.0% were using CGM alone or an insulin pump with CGM.

“Among both socially advantaged and disadvantaged participants, the majority with an HbA1c ≤7.0% or 7.1%–8.0% were using CGM alone or an insulin pump with CGM (Supplementary Figure 1).”

Income <$80,000 is associated with higher odds of any diabetes hospitalization.

“Income <$80 000, non‐White Race and unemployment were associated with higher odds of severe hypoglycaemia, whereas only income <$80 000 was associated with higher odds of any diabetes hospitalization (Table 4).”

Income <$80,000 is associated with higher odds of severe hypoglycaemia.

“Income <$80 000, non‐White Race and unemployment were associated with higher odds of severe hypoglycaemia, whereas only income <$80 000 was associated with higher odds of any diabetes hospitalization (Table 4).”

A gradient response was observed for all secondary outcomes with successively higher numbers of social disadvantage indicators.

“There was a gradient response observed for all secondary outcomes with successively higher numbers of social disadvantage indicators (Tables 3 and 4).”

Unemployment is associated with higher odds of severe hypoglycaemia.

“Income <$80 000, non‐White Race and unemployment were associated with higher odds of severe hypoglycaemia, whereas only income <$80 000 was associated with higher odds of any diabetes hospitalization (Table 4).”

CGM use is associated with lower odds of being in a higher HbA1c category (OR 0.74, 95% CI 0.58-0.96).

“CGM use was associated with lower odds of being in a higher HbA1c category (OR 0.74 [95% CI 0.58–0.96] for being in any higher HbA1c category)”

Annual household income <$80,000 is associated with lower odds of insulin pump use (adjusted OR 0.64, 95% CI 0.50-0.82).

“Annual household income <$80 000 (adjusted OR 0.64 [0.50–0.82]), no post‐secondary education (adjusted OR 0.62 [0.46–0.85]), non‐White Race (adjusted OR 0.47 [0.30–0.73]) and public insurance (adjusted OR 0.47 [0.35–0.62]) were associated with lower odds of insulin pump use after adjustment for potential confounders (Table 2).”

Insulin pump use is associated with lower odds of being in a higher HbA1c category (e.g., adjusted OR 0.24, 95% CI 0.14-0.42 for HbA1c >9.0% vs ≤7.0%).

“Insulin pump use was associated with lower odds of being in a higher HbA1c category (Table 3; e.g., adjusted OR for HbA1c being ≤7.0% compared to >9.0% for non‐pump users compared to pump users 0.24 [95% CI 0.14–0.42]).”

Distribution of HbA1c category by technology utilization was similar in socially disadvantaged individuals compared to those without social disadvantage.

“Distribution of HbA1c category by technology utilization (no technology, pump only, CGM only or pump and CGM) was similar in socially disadvantaged individuals compared to those without social disadvantage.”

Odds of insulin pump use decrease successively with an increasing number of social disadvantage indicators.

“A gradient was observed with successively lower odds of using both an insulin pump and CGM as the number of social disadvantage indicators increased (Table 2).”

CGM use was more common (83% of participants) than insulin pump use (37% of participants).

“It is therefore unsurprising that CGM use was more common (83% of participants) than insulin pump use (37% of participants).”

CGM use is not associated with diabetes hospitalization (OR 1.05, 95% CI 0.59-1.87).

“CGM use was associated with lower odds of being in a higher HbA1c category (OR 0.74 [95% CI 0.58–0.96] for being in any higher HbA1c category), but not severe hypoglycaemia or any diabetes hospitalization (OR 1.11 [95% CI 0.76–1.63] and 1.05 [95% CI 0.59–1.87], respectively).”

Non-White Race is associated with lower odds of insulin pump use (adjusted OR 0.47, 95% CI 0.30-0.73).

“Annual household income <$80 000 (adjusted OR 0.64 [0.50–0.82]), no post‐secondary education (adjusted OR 0.62 [0.46–0.85]), non‐White Race (adjusted OR 0.47 [0.30–0.73]) and public insurance (adjusted OR 0.47 [0.35–0.62]) were associated with lower odds of insulin pump use after adjustment for potential confounders (Table 2).”

No post-secondary education is associated with lower odds of insulin pump use (adjusted OR 0.62, 95% CI 0.46-0.85).

“Annual household income <$80 000 (adjusted OR 0.64 [0.50–0.82]), no post‐secondary education (adjusted OR 0.62 [0.46–0.85]), non‐White Race (adjusted OR 0.47 [0.30–0.73]) and public insurance (adjusted OR 0.47 [0.35–0.62]) were associated with lower odds of insulin pump use after adjustment for potential confounders (Table 2).”

Prevalence across intersections ranged from 0.16 to 0.47 for insulin pump use.

“Less variability across social disadvantage variables was observed for CGM than for the insulin pump, with prevalence across intersections ranging from 0.16 to 0.47 for insulin pump use and 0.73 to 0.86 for CGM use.”

Annual household income <$80,000 is associated with lower odds of CGM use (adjusted OR 0.61, 95% CI 0.45-0.83).

“In contrast, only household income <$80 000 per year (adjusted OR 0.61 [0.45–0.83]) and public insurance (adjusted OR 0.61 [0.45–0.83]) were associated with lower odds of CGM use.”

Among 2380 adults with T1D in Quebec, 37.4% used insulin pumps.

“Among 2380 adults with T1D, 37.4% used insulin pumps and 82.5% used CGM.”

Public insurance is associated with lower odds of CGM use (adjusted OR 0.61, 95% CI 0.45-0.83).

“In contrast, only household income <$80 000 per year (adjusted OR 0.61 [0.45–0.83]) and public insurance (adjusted OR 0.61 [0.45–0.83]) were associated with lower odds of CGM use.”

Sex differences were not observed for CGM.

“Second, male people were consistently less likely to use insulin pumps regardless of insurance status and Race, but sex differences were not observed for CGM.”

Rates of insulin pump use varied more between intersectional categories (defined by considerations of sex, Race and insurance status) than they did for CGM.

“First, rates of insulin pump use varied more between intersectional categories (defined by considerations of sex, Race and insurance status) than they did for CGM.”

Non-White Race was associated with lower uptake of insulin pumps and CGM.

“Third, non‐White Race was associated with lower uptake of insulin pumps and CGM, with more prominent disparities observed among non‐White groups who also lacked private insurance (‘a double hit’).”

Male people were consistently less likely to use insulin pumps regardless of insurance status and Race.

“Second, male people were consistently less likely to use insulin pumps regardless of insurance status and Race, but sex differences were not observed for CGM.”

We did not detect differential benefits of diabetes technologies on HbA1c or diabetes hospitalisations between socially advantaged versus disadvantaged groups.

“Importantly, we did not detect differential benefits of diabetes technologies on HbA1c or diabetes hospitalisations between socially advantaged versus disadvantaged groups.”

HbA1c was lower among CGM and insulin pump users in the BETTER Registry.

“HbA1c was lower among CGM and insulin pump users in the BETTER Registry, which is consistent with previous studies demonstrating glycaemic benefits for these technologies.”

More prominent disparities were observed among non-White groups who also lacked private insurance.

“Third, non‐White Race was associated with lower uptake of insulin pumps and CGM, with more prominent disparities observed among non‐White groups who also lacked private insurance (‘a double hit’).”

Intersectionality has not been sufficiently studied in relation to the use of diabetes technologies.

“Furthermore, the concept of intersectionality (how different aspects of one's identity [such as Race, gender, SES] interact and impact their experiences) has not been sufficiently studied in relation to the use of diabetes technologies.”

• cites [27] Crenshaw K. Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. Routledge; 1989.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Public funding partially mitigates disparities in CGM use.

“Social disadvantage is associated with lower uptake of insulin pumps and CGM among Quebec adults with T1D, though public funding partially mitigates disparities in CGM use.”

• AssumptionRests on an assumption: In Quebec, CGM has been publicly funded for all adults with T1D since May 2021.
• AssumptionRests on an assumption: In Quebec, insulin pumps are only publicly funded for adults who initiate insulin pump therapy prior to turning 18 years old.
• AssumptionRests on an assumption: Most individuals pay approximately 100 CAD per month for the public drug programme, which includes medications in addition to CGM, whereas there are no out-of-pocket costs for an insulin pump or supplies in the insulin pump programme.

Social disadvantage is associated with lower uptake of insulin pumps and CGM among Quebec adults with T1D.

“Social disadvantage is associated with lower uptake of insulin pumps and CGM among Quebec adults with T1D, though public funding partially mitigates disparities in CGM use.”

Self-reported HbA1c has been previously validated for concordance with laboratory-measured HbA1c.

“self‐reported HbA1c as ≤7.0%, 7.1%–8%, 8.1%–9%, >9%, which has been previously validated for concordance with laboratory‐measured HbA1c”

• cites [34] Wu Z, Rabasa‐Lhoret R, Messier V, et al. Self‐reported haemoglobin A1c highly agrees with laboratory‐measured haemoglobin A1c among adults living with type 1 diabetes: a BETTER registry study. Diabetes Metab. 2022; 48(1): 101277. 34509633 sourceNot checked — no full text of the source

Accounting for the different funding policies, this finding suggests one's social position is more influential in accessing a given diabetes technology when it is not universally funded.

“Accounting for the different funding policies, this finding suggests one's social position is more influential in accessing a given diabetes technology when it is not universally funded.”

• AssumptionRests on an assumption: In Quebec, CGM are publicly funded for adults with T1D.
• AssumptionRests on an assumption: In Quebec, insulin pumps are only publicly funded for those who initiate prior to the age of 18 years.

Data in the BETTER Registry is self-reported, which may under-estimate associations between social disadvantage and diabetes outcomes.

“Furthermore, data in the BETTER Registry is self‐reported, which may under‐estimate associations between social disadvantage and diabetes outcomes.”

Reasons for CGM non-use were not ascertained.

“Since reasons for CGM non‐use were not ascertained, we cannot be certain if the 17% of individuals in the BETTER Registry who did not use CGM experienced persistent barriers in access or alternatively chose not to use CGM because of personal preferences.”

Public funding possibly partially mitigates disparities in CGM use.

“In summary, social disadvantage is associated with lower uptake of both CGM and insulin pump among adults with T1D in Quebec, though public funding possibly partially mitigates disparities in CGM use.”

• AssumptionRests on an assumption: In Quebec, CGM are publicly funded for adults with T1D.
• AssumptionRests on an assumption: In Quebec, insulin pumps are only publicly funded for those who initiate prior to the age of 18 years.

Our results therefore likely over-estimate use of insulin pumps and CGM.

“Our results therefore likely over‐estimate use of insulin pumps and CGM.”

We were not able to evaluate factors not collected in surveys, such as preferences regarding technology use, access to health care services or diabetes education.

“Fourth, we were not able to evaluate factors not collected in surveys, such as preferences regarding technology use, access to health care services or diabetes education.”

Participants in the BETTER Registry likely under-represent social disadvantage, as the proportions of participants who are White, living in an urban area and with high levels of income, education and private insurance are high.

“Participants in the BETTER Registry likely under‐represent social disadvantage, as the proportions of participants who are White, living in an urban area and with high levels of income, education and private insurance are high.”

Volunteer registries such as the BETTER Registry are susceptible to selection bias.

“Volunteer registries such as the BETTER Registry are susceptible to selection bias.”

• cites [46] Lash TL, VanderWeele TJ, Haneause S, Rothman K. Modern Epidemiology. Lippincott Williams & Wilkins; 2020. 1343 p.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

We were not able to determine which participants were using AID.

“We were not able to determine which participants were using AID; thus, further studies are required to determine the impact of AID on diabetes outcomes according to social disadvantage.”