J.P. 摩根-美股醫(yī)療用品與設(shè)備行業(yè)-糖尿病設(shè)備調(diào)查：胰島素泵和CGM市場(chǎng)展望

NorthAmericaEquityResearch

04June2021

DiabetesDevices

JPMSurvey:OutlookfortheInsulinPump&CGM

Markets

WiththenextyearsettoberichwithproductlaunchesfrommanyofthemajormanufacturersplayingintheDiabetesspace,we’veconductedourannualdiabetessurveytobetterunderstandhowcurrentandupcomingtrendsareexpectedtoplayoutinthemarket.Keytakeawaysforthesurveyare(1)pumpsandCGMpenetrationcontinuetohaveplentyofroomtoexpand,evenafterthesuccessdemonstratedtodate,(2)there’ssignificantenthusiasmforupcomingproductlaunchesfromInsulet,Dexcom,Abbott,andMedtronic,and(3)greaterpharmacychannelaccessreducesbarriersandenablesgreateraccesstobothCGMsandinsulinpumps.Thoughreimbursementcontinuestobealimitingfactortogreaterpenetration,withseveralpresentationsatthisyear’sATTDconferencelendingcredencetothefactthatCGMs/closedloopsystemshavesignificantvalueforpatientswithuncontrolleddiabetes,wecontinuetoexpectcoveragetoexpand,especiallywithinType2andOUSpatients.Asaninnovation-drivenspacewithseveralmarket-widetailwinds,wesawveryfewsurpriseoutcomesinoursurvey.Saidanotherway,thissurveyconfirmedourverybullishstanceonthediabetessector,andwecontinuetobebullishonDXCMandPODDaheadoftheG7andOmnipod5launches,ABTwithLibre3,andwhilewelikeMDToverallandthink780GandthelowerfingerstickburdenofGuardian4isasignificantimprovement,westillexpectongoingsharelosses(thoughimprovedgrowthgoingforward).

MedicalSupplies&Devices

RobbieMarcus,CFAAC

(1-212)622-6657

robert.j.marcus@

AllenGong

(1-212)622-9520

allen.gong@

SarinPMurlidar

(1-212)622-2825

sarin.p.murlidar@

Lilia-CelineBLozada

(1-212)622-1019

lilia-celine.b.lozada@

J.P.MorganSecuritiesLLC

KeyCGMtakeaways:CGMadoptiontrendsshownosignsofrunningoutof

steam,withnearlyalldoctorsinoursurveyexpectinggreaterCGMadoption

through2022inbothinsulinpumpandMDIpatients.Oursurveynoted

enthusiasmforbothG7andLibre3,whichhavelaunchesthatarearoundthe

corner,butwethinkDexcomwillcontinuetobeviewedasthegoldstandardfor

accuracyandfunctionality,withLibre3offeringamorefavorablepricepoint.

Similartopreviousyears,whilecostandpatientsnotwantingto“weartheir

disease”weremostoftencitedasimpedimentstogreateradoption,

reimbursementchallengeshaveappearedtomovefurtherdownthelist,

somethingthatcouldbeattributedtothemuchgreaterpharmacychannel

adoptionwe’veseenevensincelastyear.

Keyinsulinpumptakeaways:Whilecostandsizewereagaincitedasthe

biggestimpedimentstogreaterpumpadoption,interestingly,reimbursement

challengeshavemovedfurtherdownthelistlikewithCGM,withcomplications

andtherapyburnoutcitedasthethirdmostcommonimpediment.Aspediatric

andMedicarepopulationsbecomemoreimportantdemographicsforgreater

marketpenetration,theeaseofusebecomesmoreofadecidingfactorfor

switchingfromMDI.GivenInsulet’sfocusonthesimplifieduserexperience,

weseethisisasatrendthatshouldbenefitOmnipod5uponitslaunchinthe

comingmonths.WhileouranalysispointstoMedtroniccontinuingtoloseshare

through2022,wewouldnotethatenthusiasmfora780Glaunchisexpectedto

stabilizethisnear-termshareceding.

Seepage30foranalystcertificationandimportantdisclosures.

J.P.Morgandoesandseekstodobusinesswithcompaniescoveredinitsresearchreports.Asaresult,investorsshouldbeawarethatthefirmmayhaveaconflictofinterestthatcouldaffecttheobjectivityofthisreport.Investorsshouldconsiderthisreportasonlyasinglefactorinmakingtheirinvestmentdecision.

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04June2021

WecontinuetoseesupportforthethesisthatpharmacychannelavailabilityenablesgreateraccesstobothCGMsandpumps.WhileDexcomandAbbotthaveseenasignificantuptakeinpharmacyaccess,insulinpumppharmacyvolumesremainlimited,withonly33%ofrespondentsreportingthatgreaterthan40%oftheirpatientsreceiveordersthroughthepharmacychannel(whichmakessenseasonlyInsulet’sOmnipodDASHisavailableinthepharmacy,MedtronicandTandem’spumpsaren’t).However,47%ofdoctorsnotedthatDashiseasiertogetinthepharmacychannelfortheirType1patients,and30%forType2.Wecontinuetoexpectasteadyuptickinvolumeshere,especiallygiventhatpricecanoftenbethedecidingfactoronapump.

Tandemwasyetagainthemostpopularpumpamongrespondents,thoughInsuletisonanotableupwardtrajectorywiththegreatestsharegainsforecasted2020-2022.WhileTandemisexpectedtotake150bpsmarketsharethrough2021,itisexpectedtolose190bpsin2022asInsuletgains520bpsthrough2022,likelyattributabletohighexpectationsfortheOmnipod5launch,whichshouldbringahybridclosedloopsystemandbettersmartphonecontrol.Tandem’st:slimX2wasfavoredforbothadultandpediatricpatients,aswellasforitssize,smartphonecompatibility,easeofuse,andreliability,whilethecurrentgenerationOmnipodwasfavoredforitslowercosts.

Again,whilewe’vecoveredthisinmoredetail(seehere),wethinkOmnipodshouldleveltheplayingfieldherebyofferingthebestofbothworlds:(1)afeature-setthatmatchesTandem’sand(2)favorablepricingandreimbursementdynamicsinthepharmacychannel.AndwhileInsulet’sOmnipodDashandLegacycontinuetobefavoredinactive(47%)andyoungpatients(30%)duetoitstubelessformfactor,theOmnipod5shouldmakeitamorepopularchoiceinallpatients.Thisisamorefavorablesentimentthanwe’veseeninpastsurveys(hereandhere).

WhilewefirmlybelievethemarketislargeenoughforG7andLibre3tobothsucceed,theperceptionamongourrespondentsisthatG7isvaluableforitssuperioraccuracy,whileLibre3foritscostandeaseofuse.90%ofrespondentsreportedthattheinitiallylowerout-of-pocketcostswerea“veryimportant”factorinthedecisionprocessthatwouldleadapatienttochooseLibre3overG7.TheadditionofpredictivealertsandalarmswithLibre3alsohelpsleveltheplayingfieldhere,with63%ofrespondentsreportingthisfeatureas“veryimportant”and37%“somewhatimportant.”Regardless,doctorsinoursurveynotedsignificantenthusiasmforbothupcominglaunches,withexpectationscallingforG7tocapture32%marketsharein2022andLibre313%(assumingJan1,2022,launchdates),withDexcomtotalCGMshareinadultType1smovingfrom43%in2020to48%in2022andAbbotttotalCGMsharemovingfrom17%in2020to19%in2021.PediatricType1CGMshareshowedDexcomsharesteadyat56%,withAbbottsharemovingfrom23%to27%.However,wecontinuetoviewmarketexpansion,ratherthanshare,asthemostimportantfactortopayattentionto.

Withfewmeaningfulproductupdatessincelastyear,MedtroniccontinuestolagthepackinCGMtechnologyvs.peers.OurcollectivesurveyrespondentsreportMedtroniclosing1000bpsofType1CGMmarketshareinadultsand600bpsinpediatricfrom2020and2022.Thisdoesn’tcomeasmuchofasurpriseasthecompany’sagingtechnologycontinuestolagpeers,thoughMedtronic’sstrongandestablishedsalesforceshouldenableamorerapid780Glaunchuponapproval.Whilethecompany’spresentationsatATTDfortheGuardianSensor3/4

3

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robert.j.marcus@

NorthAmericaEquityResearch

04June2021

fornon-adjunctiveuseareastepintherightdirection,wenotethattheinitialCGMdatawasdisappointingversuspeers,withGuardian4reportingahigheraverageMARDof10-11%(vs.Dexcom’sG6/G7at~9%)andstillrequiringafirstdayfingersticktoenabletheSmartGuardalgorithm.

Lookingforwardtoupcomingtechnologies,theInsulet-DexcomOmnipod5integratedpump-CGMtookthepolepositionasthemosthighlyanticipatedplatform.Thiswasfollowedbythe780G(30%)asthesecondmostanticipatedplatform,whileBetaBionicsdual-hormoneiLet(23%)cameinaheadoftheFreeStyleLibre3(7%).

Onqualitativefeedbackregardingrationaleforthetechnologiesdoctorsareexcitedabout,proponentsoftheOmnipod5and780Gplatformsareenthusiasticaboutastepintherightdirectiontowardatrueartificialpancreassystem.Whilebothstillrequireuserinteractionforboluses,especiallyaroundmealtime,theysignificantlyreducetheburdenandnumberofinteractionsbythepatient.

4

14%

28%

57%

PediatricAdultMedicare

RobbieMarcus,CFA

(1-212)622-6657

robert.j.marcus@

NorthAmericaEquityResearch

04June2021

SurveyDetails

SurveyRespondents

Wesurveyed30high-volumeUSendocrinologistswhotreatanaverageof1,168diabetics.Thisincludesanaverageof317TypeIpatients,409Type2insulin-intensivepatients(i.e.,usebothbasalandbolusinsulin),and442non-insulin-intensiveType2patients.Alltold,oursurveyrespondentstreat9,501Type1patients,12,259Type2insulin-intensivepatients,and13,271non-insulin-intensivepatients.Thisisdividedbetween5,067pediatricpatients,20,021non-Medicareadultpatients,and9.943Medicarepatients.

Figure1:SurveyPatientCharacteristicsFigure2:SurveyPatientCharacteristics

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

PediatricAdultMedicare

Type1Type2IIType2N-II

Source:J.P.MorganDiabetesSurvey-May2021

Source:J.P.MorganDiabetesSurvey-May2021

Question1:WhatpercentageofyourType1patientsineachofthebelowpatientgroupsdoyouexpecttohaveonthefollowingtherapiesin2020?

Question2:WhatpercentageofyourType1patientsineachofthebelowpatientgroupsdoyouexpecttohaveonthefollowingtherapiesin2021?

Question2:WhatpercentageofyourType1patientsineachofthebelowpatientgroupsdoyouexpecttohaveonthefollowingtherapiesin2022?

ForType1patientin2020,insulinpumpswereusedin59%ofpediatricpatients,47%ofadults,and45%ofMedicarepatients.WenotethatthisislikelyapopulationthathashighutilizationofpumpsrelativetothebroaderType1population,forwhichweestimatepenetrationof31.6%in2020.Despitethehigherpenetration,respondentsstillexpectincreasesinpumppenetrationinalldemographics:pediatricpumputilizationisexpectedtoincreaseto61%in2021and63%in2022;adultpumputilizationisexpectedtoincreaseto52%in2021and55%in2022;andtheMedicarepopulationisexpectedtoincreaseto47%in2021andincreaseto50%in

2022.

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robert.j.marcus@

NorthAmericaEquityResearch

04June2021

Figure3:Type1PediatricInsulinPumpandMDIPenetrationRates:2020-2022

100%

80%

60%

40%

20%

0%

59%

41%

39%

36%

61%

64%

2020

20212022

Pediatric

MDIInsulinPumpOther

Source:J.P.MorganDiabetesSurvey-May2021

Figure4:AdultInsulinPumpandMDIPenetrationRates:2020-2022

100%

80%

60%

40%

20%

0%

52%

48%

47%

45%

55%

53%

2020

20212022

Adult

MDIInsulinPumpOther

Source:J.P.MorganDiabetesSurvey-May2021

Figure5:MedicareInsulinPumpandMDIPenetrationRates:2020-2022

100%

80%

60%

40%

20%

0%

45%

55%

47%

53%

50%

50%

2020

20212022

Medicare

MDIInsulinPumpOther

Source:J.P.MorganDiabetesSurvey-May2021

Question4:WhatpercentageofyourType2insulin-intensivepatientsineachofthebelowpatientgroupswereonthefollowingtherapiesin2020?

Question5:WhatpercentageofyourType2insulin-intensivepatientsineachofthebelowpatientgroupsdoyouexpecttohaveonthefollowingtherapiesin2021?

6

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(1-212)622-6657

robert.j.marcus@

NorthAmericaEquityResearch

04June2021

Question6:WhatpercentageofyourType2insulin-intensivepatientsineachofthebelowpatientgroupsdoyouexpecttohaveonthefollowingtherapiesin2022?

ForType2insulin-intensivepatients,insulinpumppenetrationcontinuestobemuchlowerthanType1patientsatjust35%ofpediatricpatients,14%ofadults,and7%ofMedicarepatientsfor2020.However,similartotheType1results,insulinpumppenetrationisexpectedtoincreaseinallexceptPediatricpatients(wenotethattheType2pediatricpopulationinoursurveywassignificantlysmaller,andresultswereskewedbyahandfulofhigh-volumedocs).Pediatricpumppenetrationisexpectedtostayat35%in2021anddecreaseto29%in2022;adultpumppenetrationisexpectedtogoto16%in2021and19%in2022,andMedicare-pumppenetrationisexpectedtogoto8%in2021and10%in2022.

Figure6:Type2Insulin-IntensivePediatricInsulinPumpandMDIPenetrationRates:2020-2022

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

35%

71%

35%

29%

65%

65%

2020

20212022

Pediatric

MDIInsulinPumpOther

Source:J.P.MorganDiabetesSurvey-May2021

Figure7:Type2Insulin-IntensiveAdultInsulinPumpandMDIPenetrationRates:2020-2022

100%90%80%70%60%50%40%30%20%10%

0%

19%

81%

86%

84%

14%

16%

2020

2021Adult

MDIInsulinPump

2022

Other

Source:J.P.MorganDiabetesSurvey-May2021

7

RobbieMarcus,CFA

(1-212)622-6657

robert.j.marcus@

NorthAmericaEquityResearch

04June2021

Figure8:Type2Insulin-IntensiveMedicareInsulinPumpandMDIPenetrationRates:2020-2022

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

10%

90%

93%

92%

7%

8%

2020

20212022

Medicare

MDIInsulinPumpOther

Source:J.P.MorganDiabetesSurvey-May2021

Question7:Inyouropinion,whatarethebiggestimpedimentstogreaterinsulinpumpadoptioninType1patients?

Forthisquestion,respondentsweregivenalistofnineoptionsandaskedtoselectallthattheyviewedaspotentialbarrierstoincreasedinsulinpumpadoptionfortheirType1patients.Onceagain,costandpatientsnotwantingto“weartheirdisease”bothprovedtobethemostfrequentlycitedfactor,by67%ofrespondents.Followingthis,50%ofrespondentsnotedthecomplexityofinsulinpumpsasabarrierand43%notedthatpatientswerealreadywellcontrolledonMDI.Reimbursementhasmovedfartherdownthelist,withonly33%reportingthisasachallenge.

Figure9:BarrierstoType1PumpAdoption

70%60%50%40%30%20%10%0%

67%

0%

67%

50%

43%

33%33%33%

3%

CostWeartheirdiseaseComplicatedMDIisfineReimbursementTimeConsumingCanonlyaffordAwarenessLackofClinical

pumporCGMData

Source:J.P.MorganDiabetesSurvey-May2021

8

RobbieMarcus,CFA

(1-212)622-6657

robert.j.marcus@

NorthAmericaEquityResearch

04June2021

Question8:Foreachofthebelowcriteria,pleaserankthetop6insulinpumpsinyourview,where1=bestinsulinpumpforthiscriterion,2=2ndbestinsulinpumpforthiscriterion,etc.

Tounderstandtheendocrinologists'perceptionsofdifferentinsulinpumps,weaskedthemtorankthesixinsulinpumpsintheUSmarkettodayonninedifferentcharacteristics:appealtopediatrics,appealtoadults,sizeofpumpandrequiredspaceon-body,CGMintegration,out-of-pocketpatientcost,easeoflearning,easeofongoinguse,interconnectivitywithsmartphoneapps,andpumpreliability.

TheTandemT:slimX2rankedveryfavorablyagainintheeyesofoursurveyedphysicianasthebestpumpinallcategoriesexceptpumpout-of-pocketcost.Conversely,Medtronics670GandInsulet’sLegacyOmnipodrankedlowerintheeyesofphysicians,cominginatorbelowaverageformostcategoriesexceptcost.

Figure10:Overallpumpappealforpediatric(age<18)patients

3.9

3.4

3.2

2.3

2.2

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Tandemt:slimInsuletOmnipodMedtronic780GInsuletLegacyMedtronic670G

X2DashOmnipod

Source:J.P.MorganDiabetesSurvey–May2021

Figure11:Overallpumpappealforadultpatients

4.0

3.5

2.6

2.1

2.7

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Tandemt:slimInsuletOmnipodMedtronic780GInsuletLegacyMedtronic670G

X2DashOmnipod

Source:J.P.MorganDiabetesSurvey–May2021

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NorthAmericaEquityResearch

04June2021

Figure12:Sizeofpumpandrequiredspaceonbody

3.8

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

4.0

3.3

2.9

2.6

2.3

Tandemt:slimInsuletOmnipodMedtronic780GInsuletLegacyMedtronic670G

X2DashOmnipod

Source:J.P.MorganDiabetesSurvey-May2021

Figure14:Patientout-of-pocketcost

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

3.23.23.3

2.72.7

InsuletLegacyInsuletOmniPodTandemt:slimMedtronic670GMedtronic780GOmnipodDashX2

Source:J.P.MorganDiabetesSurvey-May2021

Figure16:Easeofongoinguse

3.8

3.2

3.0

2.6

2.3

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Tandemt:slimInsuletOmniPodMedtronic780GInsuletLegacyMedtronic670G

X2DashOmnipod

Source:J.P.MorganDiabetesSurvey-May2021

Figure13:CGMIntegration

3.9

3.3

3.1

2.5

2.1

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Tandemt:slimMedtronic780GMedtronic670GInsuletOmniPodInsuletLegacy

X2DashOmnipod

Source:J.P.MorganDiabetesSurvey-May2021

Figure15:Easytolearn

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

3.7

3.2

3.0

2.7

2.4

Tandemt:slimInsuletOmnipodInsuletLegacyMedtronic780GMedtronic670GX2DashOmnipod

Source:J.P.MorganDiabetesSurvey-May2021

Figure17:InterconnectivitywithSmartphoneApps

3.83.8

2.9

2.5

1.9

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Tandemt:slimInsuletOmniPodMedtronic780GMedtronic670GInsuletLegacy

X2DashOmnipod

Source:J.P.MorganDiabetesSurvey-May2021

10

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robert.j.marcus@

NorthAmericaEquityResearch

04June2021

Figure18:Pumpreliability

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

3.7

3.4

3.2

2.5

2.2

Tandemt:slimMedtronic780GInsuletOmniPodMedtronic670GInsuletLegacyX2DashOmnipod

Source:J.P.MorganDiabetesSurvey-May2021

Question9:Pleaserankthefollowinginsulinpumpmanufacturersfrombest(1)toworst3)intermsoftheirsalesforcesandcustomerservicetopatients.

WhileMedtronicpreviouslytoutedabestin-classsalesforce,oursurveyrespondentsreportedTandemashavingthebestsalesforceandpatientcustomerservice,withMedtronicaclosesecond.Similartrendswereobservedforpatientcustomerservice.WhileMedtronicreceived47%#1rankingsforitssalesforcevs.Tandem’s43%,Medtronicreceivedsignificantlymore#3rankingsat40%ofrespondentsvs.Tandem’s23%.ThequalitativecommentarysuggeststhatMedtronicrepscanoftenbeperceivedas“toopushy.”

Figure19:AverageRankingofPumpManufacturers'SalesForceandCustomerService

2.5

2.0

1.5

1.0

0.5

0.0

2.1

2.0

1.9

1.9

2.3

1.8

SalesForcePatientCustomerService

InsuletMedtronicTandem

Source:J.P.MorganDiabetesSurvey-May2021

11

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NorthAmericaEquityResearch

04June2021

Table1:QualitativeResponsestoQuestion9a

Norecentinteractionswith2and3

Theyhavemoreexperience

Thisquestionisatouchmisleadingbecauseitforcesyoutorankevenwhenyouthinkthecompaniesareequivalent.IhaveonlyhadgoodexperienceswithalloftherepsofthesecompaniesWeare,however,havinganissuewithgettingDexcomtocallourpatientsbackontime

Ireallydon’thavemuchexposuretotheInsuletortandempeople

Haveheardfromcompaniesoften

Feedbackfrommypatients

Medtronicisthebest

Longestexperienceinmarket

IseethemostrepsfromMedtronic

Therepresentativesforinsulatearealwaysreadilyavailable,helpful,respectfulofmytime

Medtronicrepsandsalesareaggressive

Tandemhasanexcellentsalesforce,andIhearveryfewpatientscomplainingabouttheircustomerservice.

Insulethadagoodsalesforceinmyareaforalongtime,thentheywentdark,andnowarestartingtocomeback.

Medtronichasanactivesalesforcebuttheyhavealwaysbeenquitepushy.Patientsfrequentlycomplainaboutcustomerservice. LeastexperiencewithTandembutlongrelationshipswithothershelps Serviceisconsistentandreliablewithpositionnumber1 Justbasedonmyexperienceswithbothsalesforceandcustomerservicewiththesecompanies. FeelTandemiseasiesttoreachandmostpatient-focused. Tandemhasthemosthelpfulreps.Theygooutofthewaytoassistpatients.Medtronicsometimesoverlyaggressive. MedtronicrepispushyandunprofessionalbuteveryoneelseatMedtronicseemsgreat Medtronicsalesteamgivesfullsupportandstopsbyoften,followedbytandem.IrarelyeverseeInsuletrepsduetolackofsupport/followup EasyaccesstorepfromMedtronic Easytoreachreps,responsivewhenneeded,patientscanreachcustomerrepresentativesandhaveissuesaddressed MoreinteractionwithMedtronic,overallnotbad. Medtronicveryaggressive Medtronichashadyearstodevelopbothaspectsandcontinuestobetheleader Medtroniciseasytoreachforpatients,lesstimeonholdandtherepsaregreataboutreturningcalls

Ihavenotseenanytandemsalesforce

Medtroniccustomersupport,patientsupporthastakenanosediveforourarea-theyaredifficulttogetaholdof,difficulttoaskforhelpandsupport. Overall,terribleexperiencewithsales/customerservice.TandemisbyfarthebestwithInsuletaclosesecond. Theproductworksalotbetter. Justmyanecdotalexperience

Medtronichasproventobethereforpatientsandproviders.Ibelievetandemhasagoodproductbutpoorcustomerservicerelyingontheirtechnologyto keeppeoplewiththemdespitetheircustomerservice.

Source:J.P.MorganDiabetesSurvey–May2020

Question10:Howimportanttofutureinsulinpumpadoptionistheabilityforpatientstobeabletocontrolthepumpfromtheirsmartphone?

Withthemuchdiscussedtransitiontoaninsulinpumpcontrolleddirectlybyapatient’ssmartphone(actuallydosinginsulin,notjustmonitoringinsulinlevels)nearingwithInsulet’sOmnipod5hybridclosed-looppump,weaskedthesurveyeddoctorstodescribehowimportantthisfeaturewillbebyselecting“notimportant,”“mediumimportance,”or“veryimportant.”Notably,only3%ofdocsthoughtthat

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smartphonecontrolwouldbe“not