Quantitative and qualitative analysis of the quality of life of Type 1 diabetes patients using insulin pumps and of those receiving multiple daily insulin injections

Study participants

We enrolled 87 T1DM patients in the quantitative part of the study: 20 pump users and 67 injection users. Both groups included mostly women. Pump users generally had at least some secondary education and had higher incomes, while injection users mostly had just a high school education. Pump users were younger (mean age 21.5 years, standard deviation (SD) 4.4) than injection users (mean age 33.6 years, SD 11.0). The groups did not differ by other socio-demographic characteristics.

HbA1c values at the last medical check did not differ significantly between the groups. In both groups, most of the patients performed one medical check during 2020 and till May 2021. Only 10% of pump users and 15% of injection users mentioned four medical checks during this period. There were no differences between pump users and injection users in this parameter. T1DM-related expenses were statistically significantly higher for pump users: for 94.7% of them, these expenses were more than 100 EUR/month; just 29.2% of injection users had similarly high expenses (Table 1).

Table 1 Demographic and T1DM-related characteristics of participants, by method of insulin administrationQuality of life and self-management

The reliability of all scales was high, ranging from α = 0.75 to α = 94 for all blocks for both questionnaires (excluding the SM Diet that had medial reliability; α = 0.63). Correlation between QoL and self-management was weak and partly insignificant. Self-management blocks correlated among themselves significantly, but not strongly (Additional file 1: Table S1). No significant relations were found between the number of tests and three self-management blocks (p = 0.12, p = 0.86, and p = 0.36, respectively).

Significant differences at the 0.1 significance level were observed between user groups in their Therapy and Concerns blocks, and in Total QoL. The highest values for both groups were found for Therapy and Communication blocks of QoL. There were no significant differences between groups in their self-management blocks (Table 2). Univariate relationships were found between Total QoL and sex (p = 0.03).

Table 2 Quality of life and self-management, grouped by method of insulin administration

In fully adjusted multiple regression models, pump users were seven times more likely to have a high Total QoL than injection users (OR 7.38; CI 0.87; 62.9). Factors that increased Total QoL were lower age, male sex, lower T1DM expenses (the most prominent association), more years living with T1DM, and better self-management. Most of the confidence intervals were wide, pointing to the low number of participants in the study (Table 3). However, the post hoc calculated power of analysis was 70.1% (p = 0.01), indicating the study’s medial power.

Table 3 Association between Total QoL and demographic and T1DM-related factorsAdditional and sensitivity analyses

For pump users, the main reason to use a pump was improved QoL; this was mentioned by 90% of them. For injection users, the median time they had been using insulin injections was eight years, and the main reason for not using a pump was its cost, as mentioned by almost half of these respondents. Of the 13 patients that previously used a pump, the main reason why they stopped was the cost (mentioned by 46.2% of those that stopped using a pump) (Additional file 1: Table S2).

In the univariate analysis between the Therapy block of QoL and demographic and T1DM-related factors, significant relationships at the 0.1 significance level were found for years with T1DM (p < 0.01) and T1DM expenses (p = 0.08); for the Communication block, significant univariate relationships were found for the number of hypoglycemic episodes per week (p = 0.09) and sex (p = 0.07). Consistent with the main analysis, male sex, lower T1DM expenses, and years living with T1DM were associated with better Therapy and Communication blocks (Additional file 1: Table S3).

Qualitative part of the study

Of those included in the quantitative part of the study, 8 pump users and 13 injection users also participated in the qualitative interviews; 15 of these were women. The men-women proportion in each study arm was similar to that in the quantitative part of the study.

The age of the interviewees ranged from 18 to 50 years, and years with T1DM ranged from 1 to 35. Eight participants did not have T1DM diaries, three had one only at the beginning of their treatment, two use them only for visits with a physician, and six regularly recode their activities in their diaries (two using an app to do so). One participant kept a diary when she used multiple insulin injections but stopped when she switched to an insulin pump (Table 4).

Table 4 Main characteristics of interviewed participants

Analysis of 40 identified codes of the interviews revealed three major themes of answers: diagnosis-related, daily self-management, and life with T1DM. Each of the major themes was further divided into three to four subcategories (Table 5). Here we will present a part of the results related to one subcategory for each category of answers: perception of diagnosis (major theme: diagnosis-related), insulin administration (major theme: daily self-control), and T1DM-related costs (major theme: life with T1DM).

Table 5 Categories of answers of interview participantsPerception of diagnosis

Before their diagnosis, most participants had had some symptoms that they had not related to T1DM, such as thirst, frequent urination, weight loss, and weakness. Therefore, for nearly all of them, the diagnosis was unexpected and shocking. For example, I, who was diagnosed at the age of 28 after being hospitalized due to T1DM:

I didn't know anything before, it seemed to me that diabetes could be born or not. I was so bad in that resuscitation because I was in a severe hypoglycemic condition … my head was dull … it was so hard to grasp.

This reaction was not related to the participant’s age at the time of diagnosis (Additional file 1: Supplement 5).

Insulin administration

One of the main reasons to use an insulin pump was the QoL that it provides (Additional file 1: Supplement 6). For example, M said:

I have much more control with the pump, because I can adjust insulin doses if necessary, and adjust the time for basal insulin. I can stop insulin if needed. with the syringe, you are injecting and then you can no longer control what is going. The pump gives much more control to both the doctor and the patient, if a person understands how the pump works. But that's what training is for.

However, some of the injection users saw positive aspects in their treatment method as well. For example, I, who uses the injections:

When using injections, it is nice to inject insulin once and that is.

F, who has used injections for 31 years, was categorically opposed to the idea of a pump:

No, never! It is not practical for me to have a foreign object that is always present at my waist area. I feel very uncomfortable. That limits me.

To summarize: although QoL was mentioned by most of the participants as the determining factor for use of the pump, some participants feel that a pump is less comfortable and even disturbing. This supports the quantitative result showing a lack of proper relations between the method of administration and QoL.

T1DM-related costs

Most pump users in our study mentioned the cost of this administration method (Additional file 1: Supplement 7). For some participants, the decision whether to use a pump depends on the monthly costs. For example, K said:

It is an extra investment [talking about the pump]—now I have needles and insulin for free, I do not have to buy anything extra—just those test strips, because the glucometer is also free for me. Together it's pretty affordable.

D switched from the pump to injections several times because of financial problems:

I had already used it [pump] as a child, I was 13 years old. […] I used to have insulin pens, but then my mom saved money so I could have the pump. […] After that I had to switch back to insulin pens because I was in big financial trouble. However, I really wanted to get back to the pump.

In Latvia, state reimbursement for insulin pumps is possible until the age of 18. Thus, some people are forced to switch to injections at that point. For most of the participants who would like to use an insulin pump, treatment-related costs are too high, and some of them were forced to change to the cheaper injection method. This supports the quantitative result of the study on the relation between T1DM-related costs and QoL.

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