A recent study in Diabetes Technology & Therapeutics has revealed a shocking disparity between the United States and Europe: Children, teens, and young adults with type 1 diabetes in Europe are doing far better than their peers in America.
Europeans under the age of 25 had significantly lower A1Cs than their American equivalents across the board, no matter their insulin delivery method or continuous glucose monitor (CGM) status.
76 percent of European youngsters use a CGM, compared to only 49 percent of Americans.
The study compared two large data sets, one from each side of the Atlantic. In the US, the researchers employed the T1D Exchange Quality Improvement Collaborative, which collects data from over 75,000 individuals with type 1 diabetes from over 50 healthcare sites. In Europe, it was the Diabetes-Patienten-Verlaufsdokumentation, a registry with hundreds of sites in Germany, Austria, Luxemburg, and Switzerland. (As a result, the study is not necessarily a representative sample of the entirety of Europe.)
Here are the blood sugar results in more detail:
USAEurope
Insulin pump with CGM8.1%7.7%
Insulin pump without CGM8.3%8.0%
Multiple Daily Injections with CGM8.7%7.6%
Multiple Daily Injections without CGM9.1%7.9%
Even American youngsters with both advanced technologies at their disposal, an insulin pump and a CGM, had a higher A1C than European youngsters with neither.
The question is, why has America fallen so far behind?
The new study was not designed to answer that question, but the authors offered some speculation, including differences in regulatory approval, insurance coverage, and cost of device, or underlying deficits in health equity.
Regulatory approval differences. As I write this article, the Dexcom G7 has been approved for use in Europe, and has been launched in several countries worldwide, but it still awaits approval in the United States. The Freestyle Libre 3, which has only recently become available in the US, was also launched first in Europe. While swifter regulatory approval might help explain why more Europeans have access to CGM technology, it doesn’t really illuminate why European youngsters have better glycemic control regardless of CGM status.
Insurance coverage & cost of device. This must be the biggie. In most Western European countries, 100 percent of the population has health insurance. (The rate of uninsured is higher in some Eastern countries, such as Bulgaria and Romania, that were not sampled in the study.)
By contrast, about 26 million Americans have no health insurance at all — slightly under 10 percent of the population — and it’s fair to presume that few of them are able to purchase the latest in diabetes tech off the shelf. The vast majority of children in the US are insured, thankfully, but the number of uninsured youngsters still necessarily dwarfs that of Europe.
Even for those that do have insurance, however, a continuous glucose monitoring system can remain out of reach. For the millions of Americans on high-deductible plans, for example, insurance might offer almost no reimbursement for a CGM system at all. Just think about how many Americans cannot afford to pay for the insulin they need –—about 20 percent of adults under the age of 65, according to the latest research — a drug that is completely necessary. A CGM is, in comparison, a luxury item.
Meanwhile, the situation is very different in most of Europe. In Germany, for example, health insurance is universal and there is significantly less income-based disparity in the quality of medical care. To put it simply, whether you do or do not have a lot of money, the government takes care of you. If your doctor and insurance agree that you need a CGM, you’ll get one, for either a nominal fee or zero dollars.
Underlying deficits in health equality.
The simple fact is that people in the United States are less healthy. This is perhaps best expressed by life expectancy: Americans live several years fewer than the citizens of every other comparable nation. Why? The explanation must be very complex, but it’s tough not to lay some blame on the maddening American healthcare system.
A Council on Foreign Relations analysis determined that the United States has the single worst public health system of any high-income nation. And a Commonwealth Fund report found that the US had by far the largest income-based healthcare disparities of any comparable nation.
We are all now painfully aware that a horrifying number of Americans cannot afford the insulin that they need to live — and nothing will harm glycemic outcomes quite like insulin rationing. But the same access problems likely apply to other resources too, including quality diabetes management education. And how about glucose test strips, which are distributed to patients in such a crazy way that a robust black market has emerged?
Could there be other factors at play? Sure. For example, perhaps Europeans, for some cultural reason, are more likely to take care of their health. One complex but semi-measurable factor is diet — America appears to drink about about 50 percent more soda per capita than Germany does, for example.
Whatever the reasons, the takeaway is unavoidable: The United States has some work to do. Young people with type 1 diabetes are not receiving the quality of care that they could be, and their health will suffer for it.