However, studies from the past three decades revealed a decrease in diabetic ketoacidosis in pump wearers compared with patients using MDI therapies (Bruttomesso 2009).
• Skin irritation and infusion site infections. People with sensitive skin may develop redness, tenderness, itching, or rashes from the infusion set or pump self-adhesive tape. Those who perspire heavily or participate in water sports may have problems with getting the tape to stick to their skin. Removing the adhesive may also cause concern. Site infections can occur from poor insertion technique or leaving the infusion set or pump (if applicable) in place too long.
• Logistics/placement. Although the insulin pump weighs about 4 oz and is smaller than a smart phone, wearing it creates challenges. Despite offering flexibility in lifestyle, many people may find it unpleasant or intolerable to be connected 24 h a day to a small external device. Pumps that use tubing to connect to an infusion set require a clip, a case with a built-in clip, or a belt-loop case for attachment. Some people prefer to place their pump in a pocket, whereas others may choose to wear their pump discreetly under clothing. Tubeless or patch pumps cannot be moved into pockets. They can be placed under clothing, but when wearing or changing clothes that do not cover or “hide” them (such as sleeveless tops or low-waisted slacks), because the pump’s adhesive is applied to the skin, the pump is immovable until the infusion set and site are changed several days later. Intimacy/sexual activity, showering or bathing, exercise, and contact sports create additional challenges in how to wear the pump.
• Medical requirements. Some insurance companies may require that a potential pump patient provide SMBG records and/or a medical necessity form completed by the healthcare professional, as well as certain lab reports (such as recent A1C or C-peptide levels) before the patient is “approved” for the purchase of an insulin pump.
• Paying for it. In 2013, the average price of an insulin pump is between $6,000 and $8,000. Disposable supplies, including pump batteries, insulin cartridges/reservoirs, infusion sets, and skin preparation products can add up to an additional $1,500 or more per year. As of this writing, a recent introduction to the pump market offers a lower initial “setup” cost but requires disposable components that may cost slightly more than standard pump supplies, thus enabling the disposable components to be covered under a patient’s insurance for supplies rather than durable medical equipment. In general, increased insurance reimbursement for pump therapy has helped to increase its use (Scheiner 2009). Some insurance companies cover all or some of the expense, whereas others may provide for only the pump and not the supplies, or vice versa. Advise your patient to be thoroughly familiar with the costs before making a commitment to pursue pump therapy. Pump manufacturers are happy to work with a potential pump patient’s insurance company to investigate coverage and out-of-pocket costs.
References
American Diabetes Association: Continuous subcutaneous insulin infusion (Position Statement). Diabetes Care 27(Suppl. 1):S110, 2004
Bruttomesso D, Costa S, Baritussio A: Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy. Diabet Metab Res Rev 25:99–111, 2009
HSBC Global Research: Diabetes: proprietary survey on insulin pumps and continuous blood glucose monitoring. Healthcare U.S. Equipment & Supplies, 2005
Scheiner G, Sobel RJ, Smithe DE, Pick AJ, Kruger D, King J, Green K: Insulin pump therapy: guidelines for successful outcomes. The Diabetes Educator 35(Suppl. 2):29S–43S, 2009
U.S. Food and Drug Administration, General Hospital and Personal Use Medical Devices Panel: Insulin Infusion Pumps Panel Information, 2010
Chapter 2 Pump and Infusion Set Options and Selection
Karen M. Bolderman, RD, LDN, CDE
Susan L. Barlow, RD, CDE
Pump Features
Several manufacturers sell insulin pumps and infusion sets. A pump company may offer more than one model. Each pump has slightly different features. And there are many different types of infusion sets available for pumps that are connected to the patient with an infusion set (versus a “patch/pod/tubeless” pump).
What kind of pump—standard with tubing and infusion set or “patch”/pod? A pump that is totally “contained,” or one that has a disposable component to it? The latter style pump’s settings are programmed into the “hardware” part of the pump and the section of the pump containing a pre-filled insulin cartridge is connected to the main component section, used for several days (with tubing attached to the person’s body), removed, and replaced, thus saving on the initial financial investment. There are many different pump brands and models to choose from.
Most pumps connect to the body via tubing of various lengths and an infusion set. A patch/pod or “tubeless” pump system consists of an integrated glucose meter and remote control device to operate the insulin “pod,” which is attached to the skin similarly to an insulin infusion set with self-adhesive tape. An insulin pod is a combination of an insulin pump cartridge/reservoir and infusion set. The patient fills the pod with the amount of insulin to be infused over several days and attaches the pod via the built-in cannula. A patch/pod pump eliminates the need for tubing, as the infusion set and pod holding the insulin are an integrated system. The pod delivers the insulin using the remote control device that is programmed with the user’s pump settings, such as basal rates, bolus options, etc. Some models provide the option of delivering a bolus directly from the pod.
After 2–3 days’ use, the pod is disconnected from the skin and discarded, and replaced with a new pod that the pumper again fills with the appropriate amount of insulin. A pod is shaped similarly to a small half hard-cooked egg and is attached to the body with self-adhesive tape. Once in place, it is not “moveable,” as there is no tubing. Patch or “pod”-style pumps provide another option in pump therapy without the “hassle” factor of tubing. Many people prefer the freedom that a tubeless pump allows, while other people may not like the “immovable lump” appearance of the patch pump and might prefer to “move the pump around” and wear it outside or inside clothing. Of course, pod placement can be as discreet as wearing a tubing-style pump under the clothing.
Insulin Pump Options and Selection
Experience with one brand of pump may bias a physician or educator toward that pump even when another brand or model may suit the patient as well, or better. Sometimes clinicians assume that their personal preferences for pump features are the same as the patient’s. As much as possible, allow the patient to choose their pump. Remember that you are preparing and managing the patient’s pump therapy, NOT training the patient on the “buttonology” or button-pushing aspects of the pump. Don’t allow your personal pump brand choice, bias, or comfort level with a particular brand dictate the pump the patient chooses. The patient’s preference is paramount and can be a factor in successful implementation of pump therapy.
Deciding on a suitable choice usually takes time. Give the patient enough time to read the marketing literature, surf the various pumps’ websites (some have “virtual” interactive pumps to simulate use/practice), view the various pump manufacturer DVDs, review diabetes publications comparison lists and articles about pumps, and meet with the pump manufacturer sales representatives and/or clinical staff. As the prescribing clinician, if you have been provided with several manufacturers’ “demo pumps,” offer to demonstrate several pumps to the patient. This may be helpful after the patient has done some research and is able to discuss features that appeal to them. Remember that, like all cars that get you from one place to another, all pumps deliver insulin but vary in their colors, options, features, and degree of sophistication.
Pump Criteria Checklist
General
Is the pump a patch/pod type, eliminating the need to be “connected” to infusion set tubing 24/7 but requiring a remote device or wireless device/meter combination for all programming?
Does