Determining Insulin Pump Candidacy: The Disconnect Between Clinical Care Guidelines and Clinical Practice.

Objective: We evaluated provider sentiments and practices that influence recommendations for insulin pump use. Methods: We surveyed US adult endocrinologists and used descriptive statistics to assess guideline adherence and criteria for insulin pump candidacy. Providers were categorized as permissive or selective prescribers based on reliance on criteria outside of clinical guidelines. Adjusted logistic regression identified factors associated with selective prescribing. Results: In 2023, we emailed surveys to 5684 endocrinologists, and 299 (5%) responded. Criteria for insulin pump use varied across providers: carbohydrate counting (55%), a minimum number of daily glucose checks (51%), a minimum number of clinic visits (48%), continuous glucose monitor use (42%), a minimum duration after diagnosis (20%), and a specific A1c (8%). While 94% reported being aware of diabetes care guidelines, 52% almost never referenced guidelines when determining insulin pump candidacy. The majority reported relying on their own judgment about insulin pump candidacy when it conflicted with clinical guidelines. Selective prescribers were more likely to report using guidelines sometimes or more (vs not often/never), have a low proportion of diabetes in their clinical case mix, and see patients primarily with public insurance. Conclusion: Less than half of endocrinologists referenced national guidelines for pump candidacy, with many relying on nonevidence-based criteria. These findings demonstrate an important disconnect between guideline recommendations and clinical practice that may lead to underutilization of insulin pumps, which can enhance diabetes care and outcomes. Additional work is needed to better align clinical practice with current recommendations.