This is the first study to analyse subscription rates to a large medical identification jewellery service in children and young adults with T1DM. Based on national prevalence estimates, utilisation was very low, with only 7% of the estimated people with T1DM aged 0–24 in Australia having a subscription (comprising 5% active and 2% inactive) to the largest and physician-preferred provider. Subscription rates varied by age and geographic region, suggesting that medical advice and patient factors play a key role in medical jewellery utilisation. The utility of the jewellery may be limited by extremely low (1.8%) rates of engraved instructions for management in the setting of an emergency.
Overall, there was little gender variation in active subscription rates, except for in those aged under 4 years and in young adults. In the very young, males held active subscriptions at double the rate of females. While the rate of active subscriptions fell in males during young adulthood, subscription rates in females increased. This may reflect a greater personal or social acceptance of the use of medical jewellery in females or suggest that females have closer contact with healthcare providers than males in this age group.
There was considerable variation in medical jewellery subscription rates by patient age. Subscriptions were infrequent amongst pre-school aged children, possibly reflecting the close parental oversight of diabetic children in this age group, and a subsequent belief that there would be little to gain from the use of a medical identification subscription and jewellery. Subscription rates increased throughout childhood and peaked among teenagers, likely reflecting parental efforts to ensure their child’s safety during what is often a time of increased independence and risk-taking behaviours.
By contrast, subscription rates fell slightly amongst males in the 20–24 year age group. This fall in adherence could be the result of several factors, including an inability or hesitancy to pay the subscription fee (AUD $52) in the context of increased financial responsibility; a lack of appreciation for the utility of the membership; social unacceptability of jewellery use; a decision to transfer to a different provider; or less frequent contact with a health professional or clinical team compared to the more intense input provided during childhood and teenage years [21, 22].
The impact of social factors in determining usage of medical identification jewellery is emphasised by the similar uptake patterns found in children and adolescents with adrenal insufficiency, where usage was low in those aged under 4 years, increased with age, peaked in teenagers, and dropped off significantly in early adulthood [23].
Young adulthood has long been recognised as a particularly vulnerable period for people with T1DM [21]. It is underscored by the transition from paediatric to adult healthcare, which is a time where people with T1DM are at high risk for loss to follow-up, poor glycaemic control and increased hospitalisations [23, 24]. Moreover, it is typically during these years that alcohol and other recreational substances become increasingly prevalent in social settings, which has been associated with impaired diabetes self-management and hypoglycaemia [25, 26]. For these reasons, medical identification jewellery could be of particular benefit in this age group and, given adherence rates have been shown to improve following in-clinic education programs in people with adrenal insufficiency, emerging adults with T1DM should be a focus for future interventions [19].
There were marked differences in subscription rates between states, with the highest rates of active membership reported in South Australia and Western Australia. The geographical variations in subscription rates may also reflect a local relationship between clinicians and the provider, as the head office was initially based in Western Australia and is now based in South Australia. Notably, a similar pattern of uptake in Western Australia and South Australia was found in both the adult and paediatric populations of people with adrenal insufficiency, emphasising the impact of local factors in uptake, irrespective of the disease [22, 23]. It may be that variations in practice among diabetes physicians or diabetes educators between states underlie the very different rates of uptake and this is a factor that could be investigated. Similarly, it would be of interest if the use of MedicAlert is stimulated by experience of a diabetic emergency and associated hospital admission.
Hypoglycaemia and ketoacidosis are persistent potentially life-threatening complications of T1DM, and hence require timely recognition and treatment [27]. In the event that a person is unable to self-treat or communicate a diagnosis, medical identification jewellery serves to facilitate both prompt identification of diabetic status, and for the lay person, provision of basic management instructions [16, 28, 29]. In this study, most people had phrases like ‘diabetic on insulin’ engraved onto their emblem. Although this may be sufficient to alert trained emergency personnel to consider a glycaemic event as a potential cause of the person’s state, misinterpretation by the lay person could have fatal implications if, for example, insulin was to be administered in the setting of hypoglycaemia.
Although there are currently no guidelines as to the most appropriate inscription, instructions such as ‘diabetic give sugar or glucagon’ may be more appropriate in providing simple guidance to any non-medical emergency attendant and would carry minimal risk of harm if administered to a hyperglycaemic patient [30]. The emergence of nasal glucagon for hypoglycaemia resuscitation will make its administration by untrained individuals simpler and quicker so its inclusion on medical identification jewellery will be pertinent. Regulating the use of medical identification in Australia, including standardised inscription guidelines, would possibly improve both the safety and utility of medical identification jewellery [28].
Although the findings of this study provide important information on the usage patterns of medical identification jewellery in people with T1DM, there are some limitations. While the data for this study was extracted from the largest medical jewellery subscription service in Australia, it is only one of many providers offering to engrave jewellery (but without a 24 hour telephone emergency service). In addition, all data obtained from the provider was patient-reported, meaning information may be inaccurate or out of date. Although active subscriptions represent current subscribers, they do not necessarily reflect correct usage (wearing jewellery at all times) which may vary between age and sex. Likewise, it is possible that those with lapsed subscriptions may continue to wear the jewellery in the absence of the telephone response service. The reasons for lapsed subscriptions are unknown, and could potentially be due to emigration overseas, converting to a different service provider, or, in a small number of people, unreported death. Moreover, in the absence of national data for the diabetic population in each state, the number of diabetics in each state was estimated using data from the NDSS. While not all diabetics are subscribed to the NDSS, given the incentives they provide to people with diabetes, including subsidised glucose monitoring products, insulin pen needles and pump consumables, it is assumed that it captures almost all Australian patients.
In conclusion, this is the first study to examine patterns of uptake and adherence to subscriptions for medical identification jewellery in people with T1DM aged 24 years and under. Communication of a diagnosis of T1DM and emergent glycaemic management is critical in preventing morbidity and mortality associated with hypo-and hyper-glycaemic episodes. In situations where patients are too unwell to communicate a diagnosis, or self-manage blood sugar levels, use of medical identification jewellery, with clear emergency instructions inscribed on the emblem, may be lifesaving. Our study, however, found that usage rates were very low, and that factors such as exposure to healthcare providers, local connections to medical identification jewellery services, and social and economic overlays may influence uptake, and should therefore be addressed as areas for improvement.