Impact of government-funded insulin pump programs on insulin pump use in Canada: a cross-sectional study using the National Diabetes Repository

Probably not a substantial claim: may not pass S3 (load-bearing).

Insulin pump therapy reduces the rate of severe hypoglycemia.

“reduces the rate of severe hypoglycemia”

• cites [2] sourceNot checked — no full text of the source
• cites [3] sourceDisputed

  The Results (Hypoglycemia) report one severe hypoglycemic event in each of two participants in both the pump (CSII) and injection (MDI) groups, not a lower rate with pump therapy. The Conclusions likewise describe similar hypoglycemia outcomes for the two regimens. (LLM, conf=0.90)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured
• cites [4] sourceNot checked — no full text of the source
• cites [5] Misso, 2010, Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus, Cochrane Database Syst Rev sourceNot checked — no full text of the source
• cites [6] sourceDisputed

  The Results (Secondary outcomes, Hypoglycaemia) report that severe hypoglycaemia fell across both treatment groups, but its rate during follow-up did not differ between pump therapy and multiple daily injections. The paper therefore does not find a reduction attributable specifically to pump therapy. (LLM, conf=0.89)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured

May combine two claims.

These differences in insulin pump use have been observed in both countries with insulin pump funding programs (New Zealand, Denmark, France) and those without (USA, Brazil).

“These differences have been observed in both countries with insulin pump funding programs (New Zealand, Denmark, France)9–11 and those without (USA, Brazil).12 13”

• cites [9] Wheeler, 2019, District health board of residence, ethnicity and socioeconomic status all impact publicly funded insulin pump uptake in New Zealand patients with type 1 diabetes, N Z Med JNot checked — no full text of the source
• cites [10] sourceNot checked — no full text of the source
• cites [11] sourceNot checked — no full text of the source
• cites [12] sourceNot checked — no full text of the source
• cites [13] sourcePartly supported

  The Utilization of diabetes technology and aspects of diabetes management section reports racial disparities in insulin pump use in the U.S. registry. The paper does not report pump-use differences in Brazil or establish whether either country has an insulin pump funding program; the funded-country examples are attached to other citations. No page number is available in our copy. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Insulin pump therapy has potential advantages compared with multiple daily injections, including improved glycemic control, reduced rate of severe hypoglycemia, greater flexibility, and higher quality of life.

“Potential advantages of insulin pump therapy compared with MDI include improved glycemic control, reduced rate of severe hypoglycemia, greater flexibility, and higher quality of life.2–6”

• cites [2] sourceNot checked — no full text of the source
• cites [3] sourcePartly supported

  The introduction reports earlier studies finding better A1C control and less hypoglycemia with pump therapy, while limiting a proposed benefit for severe hypoglycemia to selected people with recurrent episodes on NPH-based injections. This study’s Results found similar glycemic control and severe-hypoglycemia events with the two regimens. Treatment satisfaction favored pumps on one measure, but the copy does not establish greater flexibility or higher quality of life. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites [4] sourceNot checked — no full text of the source
• cites [5] Misso, 2010, Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus, Cochrane Database Syst Rev sourceNot checked — no full text of the source
• cites [6] sourcePartly supported

  The Introduction reports observational evidence of improved glucose control, reduced hypoglycaemia risk, and enhanced quality of life with pumps; the Discussion also reports fewer dietary restrictions. But the Introduction does not specify severe hypoglycaemia, and the Results (Secondary outcomes) found no significant difference in severe hypoglycaemia rates between pumps and multiple daily injections. The claimed reduction in severe hypoglycaemia relative to injections is therefore not supported by this trial. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

Among adults with type 1 diabetes, individuals who are older, male, ethnic minorities, or of lower income are significantly less likely to use insulin pumps.

“Indeed, among adults with type 1 diabetes, individuals who are older, male, ethnic minorities, or of lower income are significantly less likely to use insulin pumps.9–13”

• cites [9] Wheeler, 2019, District health board of residence, ethnicity and socioeconomic status all impact publicly funded insulin pump uptake in New Zealand patients with type 1 diabetes, N Z Med JNot checked — no full text of the source
• cites [10] sourceNot checked — no full text of the source
• cites [11] sourceNot checked — no full text of the source
• cites [12] sourceNot checked — no full text of the source
• cites [13] sourcePartly supported

  The Utilization of diabetes technology section (page not specified) reports racial disparities in pump use across all age groups, which includes adults. It does not state the direction or statistical significance of those disparities, or report that older adults, men, or people with lower incomes are less likely to use pumps. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

May combine two claims.

Among the pediatric population (<18 years old) in Ontario, the proportion using insulin pumps in 2012 was reported as 38%, though this has likely increased since.

“Among the pediatric population (<18 years old) in Ontario, the proportion using insulin pumps in 2012 was reported as 38%, though this has likely increased since.26”

• cites [26] sourcePartly supported

  The Pump Use section reports that 38% of children with type 1 diabetes in Ontario used pumps by 2012. The claim omits the type 1 diabetes restriction, making the reported proportion sound applicable to all children under 18; the source also does not establish that exact age cutoff. It documents growth through 2012, not an increase after 2012. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

Insulin pump therapy may improve glycemic control.

“insulin pump therapy may improve glycemic control”

• cites [2] sourceNot checked — no full text of the source
• cites [3] sourceSupported
• cites [4] sourceNot checked — no full text of the source
• cites [5] Misso, 2010, Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus, Cochrane Database Syst Rev sourceNot checked — no full text of the source
• cites [6] sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Education and income are correlated.

“In addition, education and income are correlated.32”

• cites [32] sourceSupported

May combine two claims.

Of the 1,559 adults with type 1 diabetes, 1,320 lived in provinces with government-funded insulin pump programs and 239 lived in provinces without.

“Of these, 1320 lived in provinces with government-funded insulin pump programs and 239 lived in provinces without government-funded insulin pump programs.”

May combine two claims.

Differences in insulin pump use within each income quintile by pump funding program status were greatest in the lowest income quintile (7% higher in provinces with pump funding programs) and the highest income quintile (5% higher in provinces with pump funding programs), whereas rates were more similar in middle-income quintiles.

“Differences in insulin pump use within each income quintile by pump funding program status were greatest in the lowest income quintile (insulin pump use was 7% higher in provinces with pump funding programs) and the highest income quintile (pump use was 5% higher in provinces with pump funding programs), whereas the rates of insulin pump use were more similar in the middle-income quintiles.”

May combine two claims.

In provinces with pump funding programs, individuals with depression were less likely to use insulin pumps (OR 0.69, 95% CI 0.55 to 0.87), whereas in provinces without pump funding programs there was no significant association (OR 1.00, 95% CI 0.55 to 1.83).

“Males and individuals with depression were less likely to use insulin pumps in provinces with pump funding programs but not provinces without (0.77 (95% CI 0.62 to 0.96) vs 0.94 (95% CI 0.55 to 1.58) for male sex; 0.69 (95% CI 0.55 to 0.87) vs 1.00 (95% CI 0.55 to 1.83) for depression).”

May combine two claims.

Persistent disparities in income quintile were observed even in provinces with pump funding programs, and disparities by income quintile were not greater in provinces without pump funding programs as would have been expected.

“However, we observed persistent disparities in income quintile even in provinces with pump funding programs, and the disparities by income quintile were not greater in provinces without pump funding programs as would have been expected.”

May combine two claims.

In provinces with pump funding programs, males were less likely to use insulin pumps (OR 0.77, 95% CI 0.62 to 0.96), whereas in provinces without pump funding programs there was no significant association (OR 0.94, 95% CI 0.55 to 1.58).

“Males and individuals with depression were less likely to use insulin pumps in provinces with pump funding programs but not provinces without (0.77 (95% CI 0.62 to 0.96) vs 0.94 (95% CI 0.55 to 1.58) for male sex; 0.69 (95% CI 0.55 to 0.87) vs 1.00 (95% CI 0.55 to 1.83) for depression).”

May combine two claims.

Older age, male sex, and higher HbA1c were associated with lower odds of using an insulin pump.

“Older age, male sex and higher HbA1c were associated with lower odds of using an insulin pump.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In GEE models, confidence intervals were wider for all estimated odds ratios.

“As expected with GEE models, CIs were wider for all estimated ORs.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

Enrollment in government-funded insulin pump programs may require fulfilling criteria and managing paperwork regularly, which could be an additional barrier disproportionately affecting individuals with a non-English primary language or lower education level.

“Enrollment in government-funded insulin pump programs may also require fulfilling certain criteria and managing and completing paperwork regularly, which could be an additional barrier disproportionately affecting individuals with a non-English primary language or lower education level.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Missing data in multivariable models were handled using multiple imputation.

“Missing data were assumed to be missing at random and multiple imputation was used for missing data in multivariable models.”

• AssumptionThe authors state this as an assumption: Missing data were missing at random.

Probably not a substantial claim: may not pass S4 (based).

Misclassification of type 1 diabetes and insulin pump use would have affected provinces with and without pump funding programs similarly, resulting in a non-differential bias.

“we expect this would have affected provinces with pump funding programs and provinces without pump funding programs similarly, resulting in a non-differential bias.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In type 1 diabetes, intensive insulin therapy targeting HbA1c ≤7.0% is the standard of care and can be delivered by multiple daily injections or continuous subcutaneous insulin infusion.

“In type 1 diabetes, intensive insulin therapy targeting a hemoglobin A1c (HbA1c) ≤7.0% is the standard of care and can be delivered by two methods: multiple daily injections of insulin (MDI), or continuous subcutaneous insulin infusion, also referred to as insulin pump therapy.1”

• cites [1] sourceNot checked — no full text of the source

May combine two claims.

The 10% difference in pump use between provinces with and without pump funding programs is valid, even if absolute numbers of pump users within each type of province may be overestimated.

“Thus, the 10% difference in pump use between provinces with and without pump funding programs is valid, even if the absolute numbers of pump users within each type of province may be overestimated.”

May combine two claims.

In Canada, healthcare is delivered provincially with funding models for insulin pump therapy differing by province.

“In Canada, healthcare is delivered provincially with funding models for insulin pump therapy differing by province (online supplemental table 1).”

• cites online supplemental table 1Not matched

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

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Sensitivity analyses were performed using generalized estimating equation models to account for clustering by primary care clinic site and complete case analyses for missing data.

“Sensitivity analyses were performed using generalized estimating equation (GEE) models as an alternative to logistic regression models in order to account for clustering by primary care clinic site.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Although insulin pump therapy is more expensive than multiple daily injections, it has been found to be cost-effective.

“Although insulin pump therapy is more expensive than MDI (annual expenses of $C6247.18 for insulin pump therapy vs $C4949.49 for MDI),7 it has been found to be cost-effective.7 8”

• cites 7 8Not matched

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

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

This study was designed and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines and the Reporting of Studies Conducted Using Observational Routinely Collected Health Data statement.

“This study was designed and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines and the Reporting of Studies Conducted Using Observational Routinely Collected Health Data statement.22 23”

• cites 22 23Not matched

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

Probably not a substantial claim: may not pass S4 (based).

Whether government-funded insulin pump programs result in more equitable insulin pump use is currently unknown.

“Whether government-funded insulin pump programs result in more equitable insulin pump use is currently unknown.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There may have been misclassification of type 1 diabetes and insulin pump use.

“First, there may have been misclassification of type 1 diabetes and insulin pump use.”

Probably not a substantial claim: may not pass S2 (checkable).

Canada is an ideal model for conducting a natural experiment assessing the impact of government funding for insulin pump therapy on rates and equity of insulin pump use, which would be broadly applicable to other regions.

“Thus, Canada is an ideal model for conducting a ‘natural experiment’ assessing the impact of government funding for insulin pump therapy on rates and equity of insulin pump use, which would be broadly applicable to other regions.”

May combine two claims.

The results for differences within income quintiles must be interpreted with caution because sample sizes by income quintile were small for provinces without pump funding programs and differences within income quintiles were not statistically significant.

“these results must be interpreted with caution since sample sizes by income quintile were small for provinces without pump funding programs, and differences within income quintiles were not statistically significant.”

May combine two claims.

Government funding may improve access to insulin pumps but may inadvertently favor those of higher socioeconomic status.

“Therefore, these findings suggest that while government funding may improve access to insulin pumps, they may inadvertently favor those of higher socioeconomic status.”

May combine two claims.

Even if the number of individuals using insulin pumps was overestimated, the bias would have been non-differential, affecting provinces with and without pump funding programs similarly.

“Even though we may have overestimated the number of individuals using insulin pumps, this would have been a non-differential bias, affecting individuals in provinces with and without pump funding programs similarly.”

May combine two claims.

Insulin pump use in the current study is similar to the 44% reported in the Canadian Study of Longevity in Diabetes, although that study represented a selected cohort of older individuals with type 1 diabetes and was susceptible to volunteer bias.

“Insulin pump use in the current study is similar to 44% reported in the Canadian Study of Longevity in Diabetes, although that study represented a selected cohort of older individuals with type 1 diabetes and was susceptible to volunteer bias.25”

• cites [25] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Individuals who recently switched from MDI to insulin pump therapy or those using basal insulin in combination with an insulin pump may have been misclassified as not using insulin pump therapy, though this was expected to be uncommon.

“Individuals who recently switched from MDI to insulin pump therapy or those using basal insulin in combination with an insulin pump may have been misclassified as not using insulin pump therapy, though we expect this would be uncommon.”

May combine two claims.

The sample size was particularly small for provinces without insulin pump funding programs, which limits comparison between groups.

“The sample size was particularly small for provinces without insulin pump funding programs which limits comparison between groups.”

May combine two claims.

The DAC National Diabetes Repository did not contain information on ethnicity, education, primary language, self-reported income, duration of diabetes, age at initiation of insulin pump therapy, diabetes complications, or use of other diabetes technologies such as continuous glucose-monitoring devices.

“the DAC National Diabetes Repository did not contain information pertaining to ethnicity, education, primary language, self-reported income, duration of diabetes, age at initiation of insulin pump therapy, or diabetes complications. It also did not include information regarding use of other diabetes technologies such as continuous glucose-monitoring devices.”

The quote only partly states this claim.

All multivariable models repeated using GEEs that accounted for clustering by primary care clinic produced results consistent with the primary analysis for the association between pump program and odds of insulin pump use.

“In addition, all multivariable models were repeated using GEEs that accounted for clustering by primary care clinic and results are presented in online supplemental tables 3 and 4. As expected with GEE models, CIs were wider for all estimated ORs. The OR for the association between pump program and odds of insulin pump use was consistent with the primary analysis.”