Are insulin pumps underutilized in type 1 diabetes? Yes.

Continuous subcutaneous insulin infusion (CSII), popularly called insulin pump therapy, has evolved from its invention in the 1970s as an experimental treatment designed to test the relationship between glycemic control and diabetic tissue complications (1) to its present status as a routine therapy for selected type 1 diabetic patients (2). However, the use of insulin pump therapy varies markedly throughout the world; there are some notable high-use countries, e.g., the U.S. and Israel, where it is estimated that ∼20% of type 1 diabetic patients use CSII (manufacturers’ estimates), whereas in other countries, such as the U.K. and Denmark, ∼1% use pump therapy (3). The reasons for this variation include the availability of financial resources and health care professionals to supervise CSII and a lack of knowledge on the effectiveness of CSII (3), but there is also disagreement on which diabetic subjects should be treated with CSII, as evidenced by both the different intercountry usage and the large number of reasons for starting insulin pump therapy (4–6). As noted by Schade and Valentine (7), “the challenge for the health care provider is to select the diabetic patients who will really benefit from pump usage.” What proportion and what types of type 1 diabetic patients should then be offered a trial of CSII on clinical grounds alone, leaving aside the legitimate issues of supply on the basis of patient preference and restrictions due to availability of funding and staffing? I shall argue that the target proportion best treated by CSII, or offered a trial of CSII, can be derived from an estimate of the effectiveness of this therapy compared with the best insulin injection treatment for particular clinical problems in type 1 diabetes. Most current guidelines (4,6) or reviews of the evidence base on CSII (2 …