Accessibility of Insulin Pumps in 2015

Accessibility of Insulin Pumps in 2015

Braille Monitor
April 2016

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Accessibility of Insulin Pumps in 2015

by Veronica Elsea
From the Editor: What does it mean to say that a particular piece of equipment is accessible, and does what that equipment is used for change the standard? The reader will notice in this article how resourceful Veronica must be in counting beeps and in pressing a button in the hope that she will be placed on the desired screen. It is one thing to say that an oven is accessible if a person can adjust its temperature in five-degree increments by counting beeps. If the oven starts at 325, setting the temperature to 450 is certainly doable. If one is off by a single press, either through difficulty in counting or a button press that doesn’t register or beep, the chances are that the food will still be edible. But if miscounting beeps or not getting a confirmatory tone changes how much medication one gives, the consequences may be very different.

Veronica Elsea is a music business owner living in Santa Cruz, California. She has produced several albums to date including "Diabetes Melodious," using her music to help others live with the day-to-day challenges of diabetes. Blind since infancy, she was diagnosed with Type 1 Diabetes in her thirties. After three years of less-than-ideal control using regular and NPH insulins, she began using an insulin pump in 1991 and continues to rely on the pump's benefits today. Since being diagnosed she has taken advantage of living close to many of the companies that manufacture diabetes management equipment, sitting down with engineers and educating them on how their equipment could be made accessible to those who are blind and visually impaired. In the early nineties she worked intensively to help persuade medical professionals that people who are blind can successfully manage insulin pumps without constant assistance from a sighted person. Over the past twenty-five years, she has offered support and encouragement to others who are blind who wish to know more about using an insulin pump through the Diabetes Action Network and personal contacts.

Today she continues to find contacts among diabetes equipment manufacturers, medical professionals, politicians, and people living with diabetes in order to educate, engineer, and advocate for improvements in equipment which would allow those who are blind and visually impaired to make use of modern equipment in gaining or maintaining optimum diabetes control. Here is what she has to say:

I have been attached to an insulin pump since September of 1991. My first pump was the H-Tron V100 from Disetronic. For the past ten years I have been using the Deltec Cozmo from Smiths Medical. Neither of these pumps are currently available. Disetronic has been purchased by Roche, and Smiths Medical is no longer in the diabetes business. Since my current pump is long out of warranty, I am quite concerned about what I'll do when it stops working.

On Saturday, March 7, 2015, I attended the day-long seminar organized by Taking Control of Your Diabetes. In lieu of attending some of the workshops, I spent most of my time in the exhibit hall visiting with all of the insulin pump manufacturers who chose to attend. I was able to spend some quality time with all of the pumps, gaining hands-on experience with each. I tried out the Medtronic MiniMed 530G, The Animas Vibe, Animas Ping, Asante Snap pump, Insulet Corporation's OmniPod, Tandem Diabetes t:slim, and the Roche Accu-Chek Spirit.

In the early nineties pumps were designed with convenience and easy access through clothing in mind. Hence, they had large, easy-to-find buttons, simply designed functions, beeps to guide the user through all processes, and only a few different functions available. With today's smart pumps, the devices take on more of the work such as figuring out carb counts, more alarms, connecting with meters and continuous glucose monitors, offering more programming options for the users. This increase in functionality has led to an increased reliance on complex menuing or "wizards" which bring up varying screens depending on the user's responses to questions. Since users are now expected to be looking at the pump screen or that of a connected meter, the easily found buttons are disappearing, and the manufacturers no longer see any need for keypad beeps, so those have all been removed.

These changes pose a considerable challenge for those of us who are blind or visually impaired because we have lost significant access to information and functions provided by the pump. As a totally blind pump user, I will begin my review by explaining what I can and cannot do with the Cozmo 1800, which I am still using.
Things I can do very easily on the Cozmo pump:

Change batteries
Fill and change cartridge
Change and prime tubing
Change and monitor cannulas (Cleo 90)
Verify that button presses succeeded because of keypad beeps
Keep track of where I am in the menus
Get myself out of the menus
Use "touch" bolus, programmed in grams of carbs
Enter BG (blood glucose) reading manually in correction bolus screen
Deliver correction bolus
Set up and deliver meal bolus on bolus screen
Set up and deliver combination bolus
Set up and deliver extended bolus
Set up and use temporary basal rates
Change time and date settings
Silence alarms
Stop pump

Things I can do very carefully or with a bit of verification by a sighted person:

Change basal rates
Restart pump after it has been stopped
Change or add new insulin/carb ratios

Things requiring initial assistance that helped:

Customize menus, removing items I could not use
Some initial pump setup was faster with assistance

Things I can do easily on the computer with CoZmanager software:

Send complete pump settings to a new pump
Verify anything changed in the pump itself
Access and change all pump settings and configuration: time/date, insulin sensitivity and duration, target BG, alarms, and more.
Change or add basal patterns
Set up temporary basal profiles

For me one of the most important benefits of using an insulin pump is taking advantage of the "insulin on board" feature, especially when correcting for high blood glucose readings. Here's a description of how I do this on the Cozmo:

I've programmed a target BG level into my pump at 100. Let's say I do a finger stick, and my reading is 180. In the Cozmo I'd do the following: hit the next button once to wake up the pump and hit it again to get into the menus. Hit down-arrow once for the correction bolus screen and press next to select it. The screen shows 100, and I must hit the up-arrow until I reach 180. So I'm listening for the keypad beeps as I count to 80.

Then I hit next to continue. At this point the screen displays either how much insulin I need or how much is being subtracted if I still have insulin remaining in my system from a previous bolus. I can't read this display, but if I hit the up-arrow and hear no beep, it means that the pump doesn't think I need any more insulin. I hit "next" again, and here I can override the pump if I choose by hitting the up-arrow till I've added the amount I want. I then hit next again to finish. This feature would not be available to me at all without the keypad beeps as feedback during the process.

On the Cozmo being able to separate the correction bolus from the meal bolus means less opportunity to forget which screen I'm on. No pump currently on the market comes with software which allows the user to program the pump from the computer using a screen reader.
Asante Snap Pump Review:

Easy cartridge loading: This pump uses pre-filled cartridges that just snap into the pump; this eliminates any worry about air bubbles.
No priming necessary
Battery is part of the cartridge which is replaced
It uses proprietary cannulas which required a bit of trickery to figure out the orientation before inserting.
Button pushes involve pressing a button on one end of the pump and confirming by pressing a button on another end, so often requiring two hands
An easy bolus can be set up, but it is way down in the menus; doing this means that we'd give up other features.
Items that one might want to ask a sighted person to review, such as amount left in cartridge or insulin on board, are way down in menus.
No keypad beeps
Button pushes are fairly steady but mistakes could happen without feedback; these mistakes happen because pressing a button too hard can cause the pump to scroll, and sometimes button presses just don't take.

Some studies were begun to develop speech output for this pump. Unfortunately Asante has gone out of business as of May 15, 2015, and this pump is no longer available. Customers are being referred to Animas.
Medtronic MiniMed 530G Review:

This pump comes with an integrated continuous glucose monitor and connects through Bluetooth to the Bayer Contour meter. During my demo it was difficult to get the representative to discuss any method of doing anything that didn't involve making use of the remote features.

Batteries easy to change
Cartridge easy to change
Priming easy
All cannulas proprietary and I found them more challenging to insert
Home screen button for getting out of menus
No easy bolus button on side or edge of pump
Easy bolus wizard still requires a lot of button pushes and pump taken out of hiding place
No keypad beeps
No way to enter correction bolus without going through wizard which includes meal bolus; this means extra steps to answer yes or no; just more opportunity to lose one's place
Easy to have someone read insulin remaining in cartridge; insulin on board is better than it used to be but still buried a bit
Can run temporary basal but tricky to change regular basal rates
Could not figure out how to enter BG reading manually
Could not figure out how to set up combo or extended bolus
Stopping the pump was reasonably easy, although this is connected with the CGM based on programmed readings
Different sounds for low and high CGM alarms but no way to read CGM output or interpret other alarms from predictive alerts
Pump cannot be used with the Dexcom Share app because it is a different model of CGM
Computer software only designed to send information from pump to healthcare team

Unfortunately the rep was so intent on telling me what was wrong with all of the other pumps that it was difficult to get some questions answered. The rep could not seem to grasp that simply using the accompanying meter and sending a blood glucose reading to the pump was not acceptable because we still need to know what our readings are.
Animas Vibe and Ping Review:

The Animas Vibe includes the Dexcom G4 continuous glucose monitor while the Ping includes a meter which serves as a remote. The meter is not accessible although those who can work with a high-contrast device may find the Animas to be a satisfactory choice.

Batteries easy to change
Cartridges easy to change
Priming easy
Cannulas and tubing: uses any luer lock sets
No keypad beeps except when using "audio bolus" button
Easy-to-feel bolus button on the end of the pump; can deliver in units of insulin, not in grams of carbs
Most actions require more confirmation steps than they do on many other pumps
Would be able to enter BG manually if one could verify by keypad beeps; as it is, pressing button a bit too hard can cause scrolling which would lead to errors
Had trouble figuring out combo and extended boluses
Did not get to try to enter basal patterns.
Custom sounds can be used for some alarms, but not critical ones like low battery or cartridge.
Pressing up- or down-arrow several times will eventually arrive at the top or bottom of a menu because menu does not wrap.
Information could be quickly read by a sighted person if desired.
Pump includes CalorieKing database, but it's not accessible.
The Vibe has a button on top which when pressed shows the output from the Dexcom; handy if there's someone else around to read it; cannot use Vibe with Dexcom SHARE.

Insulet OmniPod Review:
This pump has no tubing. Insulin is stored in the "pod," and communication occurs with a remote. Because insulin is stored in the pod, not in the main pump, this pump is not currently covered by Medicare.

The remote contains a FreeStyle meter which is not accessible. Both the pods and the remote have gotten smaller since this pump first came on the market.

Pods very easy to insert
Filling pod takes a bit of creativity if you don't fill completely. For instance, if you don't use 200 units of insulin in three days
ID screen can be daunting: To turn on pump, press "on" then one must press "yes." However, this is either the left or right soft button, and there's no way for user to know which it is for any given session.
Also requires many button presses to confirm actions. “Yes” and “no” are not always consistently assigned to predictable soft buttons.
Home button always takes user out of menus.
No quick or easy bolus option; must go through wizard.
No keypad beeps
Can enter BG reading manually but no feedback from keypad beeps; buttons don't tend to scroll so easily.
More identical-sounding alarms such as out of range of pod, malfunctioning pod, etc.
Must go very deep into menus if asking sighted person to read information.
OmniPod plans to incorporate a Dexcom CGM in the future.
Unfortunately, beginning with its next model, the OmniPod will be another touchscreen pump.

Tandem T:slim Review:
This is a touchscreen pump. Unfortunately the icons on the screen do not land in the same area for each page so a usable template could not be created to aid in locating items.

Battery charges by connecting to USB for fifteen minutes a day.
Cartridge very different from other pumps but fillable.
Priming takes longer but is doable.
Cannulas: can use standard luer lock sets; bought patents from Smiths Medical.
Very nice low-pitched confirmation and keypad beeps.
Easy quick bolus button on edge of pump; bolus in units of insulin
Screen bright with good contrast
Turning on pump depends on tricky timing and pressing a sequence of buttons.
Almost all features show varying screens after user answers question.
Could not independently perform any actions on pump.
Plans to incorporate Dexcom CGM in future model

Roche Accu-Chek Spirit Review:

The pump can be controlled on the unit itself or via a remote.

Battery changing: easy
Cartridge very standard
Priming easy
Cannulas: uses standard luer lock sets
Unit has keypad beeps and audio feedback for completion of actions
Only most basic functions can be performed from pump.
Can set temporary basals easily
Can change regular basal rates with some difficulty
All smart features require remote.
Remote has no keypad beeps.
Remote relies on "wizards" to guide user through questions; almost impossible to memorize functions or patterns
Inaccessible meter is included but does not directly communicate with pump

Dexcom G4 Review:
The unit itself is not accessible when setting alarm ranges. High and low alarms do sound different, but alarms such as problems with transmitter or receiver do not stand out. BG readings appear on the display every five minutes along with a graph which shows how rapidly the user's BG level is rising or falling.

On the unit itself, I could silence an alarm even though I couldn't identify the cause of some of them. Calibration required concentration but was possible. Dexcom SHARE™ no longer requires the user to purchase a separate receiver. The SHARE app for iDevices and Android allows the Dexcom display to be seen on the device containing the app. Screenreaders may read the most recent number, but there is no representation of the graphs. The Apple Watch is simply considered another external device and does not behave any differently from an iPhone or iPad.
I found the CGM felt like a lot of work for someone who does not have hypoglycemia unawareness.
In conclusion, I have no idea which pump I'd purchase if my Cozmo reached the end of its life today. I hope that as long as some pumps and other medical devices still rely on buttons for their operation, companies can be convinced to return keypad beeps as an option for all users. I certainly hope that the current fascination with touchscreen devices does not preclude those who are blind from obtaining the same standard of care afforded to those who are sighted. But for now, a serious gap remains.

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