title: Insulin pump use and discontinuation in children and teens: a population-based cohort study in Ontario, Canada.
abstract: To describe insulin pump use by youth since introduction of universal funding in Ontario, Canada and to explore the relationship between pump use and pediatric diabetes center characteristics and the relationship between discontinuation and center and patient characteristics.
  
  
  
  Observational, population-based cohort study of youth with type 1 diabetes (<19 yr) who received pump funding from 2006 to 2013 (n = 3700). We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. We tested the relationship between center-level pump uptake and center characteristics (center type, physician model, and availability of 24-h support) using an adjusted negative binomial model; we studied center- and patient-level factors (socioeconomic status and baseline glycemic control) associated with discontinuation using a Cox proportional hazards model with generalized estimating equations.
  
  
  
  Pump users were more likely to be in the highest income quintile than non-pump users (29.6 vs. 19.1%, p < 0.0001). In 2012, mean percent pump use was 38.0% with variability across centers. There was no association between uptake and center characteristics. Discontinuation was low (0.42/100 person-yr) and was associated with being followed at a small community center [hazard ratio (HR): 2.24 (1.05-4.76)] and being more deprived [HR: 2.36 (1.14-1.48)]. Older age was associated with a lower rate of discontinuation [HR: 0.31 (0.14-0.66)].
  
  
  
  Rates of pump use have increased since 2006 and discontinuation is rare. Large variation in uptake across centers was not explained by the factors we examined but may reflect variation in patient populations or practice patterns, and should be further explored.
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Rayzel
authors.initials: R
authors.lastname: Shulman
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Therese A
authors.initials: TA
authors.lastname: Stukel
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.|Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto, Canada.
authors.forename: Fiona A
authors.identifier: 0000-0003-4953-6255
authors.initials: FA
authors.lastname: Miller
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Alice
authors.initials: A
authors.lastname: Newman
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.
authors.forename: Denis
authors.initials: D
authors.lastname: Daneman
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Astrid
authors.initials: A
authors.lastname: Guttmann
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000188:drug therapy* / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007328:Insulin / Q000008:administration & dosage*; D007332:Insulin Infusion Systems / Q000706:statistics & numerical data; D008297:Male; D009864:Ontario / Q000453:epidemiology; D012923:Social Class; D028761:Withholding Treatment / Q000706:statistics & numerical data*
chemical_list: D007328:Insulin
keywords: adolescent; child; diabetes mellitus, type 1; health services research; insulin infusion systems