Perform structured assessment before prescribing CSII
STEP 1 — Gather Information
Collect: mental/psychological health (e.g., depression, anxiety, cognitive impairment), documented adherence to diabetes self‑care (SMBG/CGM frequency, carbohydrate counting, appointment attendance), patient‑expressed willingness and interest in trying an insulin pump, and confirmed ability to attend required follow‑up visits (typically quarterly). Document each domain in a structured checklist.
STEP 2 — Rule In / Rule Out
If any domain is markedly deficient (active untreated psychiatric illness, chronic non‑adherence, explicit unwillingness, or inability to commit to follow‑up), rule out CSII candidacy and address the deficiency; otherwise, rule in the patient for further stratification.
STEP 3 — Classify or Stratify
Classify readiness as: Ready (all four domains adequate), Conditionally Ready (one or two mild concerns that can be remedied with targeted support), or Not Ready (multiple or severe concerns requiring alternative therapy).
STEP 4 — Decide
If Ready, proceed to prescribe CSII and initiate device education/training; if Conditionally Ready, implement a remediation plan (e.g., adherence coaching, mental health referral, follow‑up scheduling) and reassess in 4–6 weeks; if Not Ready, continue optimized MDI or consider other adjunctive therapies and revisit pump candidacy after optimization.
Clinical Guardrails / Mimics / Pitfalls
Do not prescribe CSII based solely on A1C or patient request without assessing psychosocial and adherence factors. Avoid overlooking untreated depression or anxiety, which can impair pump use and safety. Never assume willingness; verify interest through explicit discussion. Ensure follow‑up feasibility before prescribing to prevent abandonment and DKA risk.
Concrete Clinical Example
A 34‑year‑old with T1DM, A1C 8.6%, reports checking glucose 4×/day, counts carbohydrates, attends endocrinology visits quarterly, denies depression/anxiety, expresses strong interest in a pump, and can commit to monthly check‑ins initially. All domains are adequate → classified as Ready → CSII prescribed with structured education plan initiated.
Source: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2534