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Time alive and free of diabetes-related complications. CSII Continuous subcutaneous insulin infusion, MDI multiple daily injections
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Introduction
Although primarily utilized in type 1 diabetes, continuous subcutaneous insulin infusion (CSII) represents a useful treatment alternative for patients with type 2 diabetes who are unable to achieve good glycemic control despite optimization of multiple daily injections (MDI). The aim of the analysis reported here was to investigate the...
Contexts in source publication
Context 1
... renal and ophthalmic complication costs were lower in the CSII arm compared with the MDI arm by more than EUR 5000 and EUR 2000, respectively. The lower complication costs in the CSII arm were driven by improved glycemic control leading to a delay in both the onset and lower cumulative incidence of diabetes-related complications in the CSII arm (Fig. 1). For example, the use of CSII was associated with mean delay in onset of [ 1 year for several complications, including retinopathy, proteinuria, neuropathy and macula ...
Context 2
... renal and ophthalmic complication costs were lower in the CSII arm compared with the MDI arm by more than EUR 5000 and EUR 2000, respectively. The lower complication costs in the CSII arm were driven by improved glycemic control leading to a delay in both the onset and lower cumulative incidence of diabetes-related complications in the CSII arm (Fig. 1). For example, the use of CSII was associated with mean delay in onset of [ 1 year for several complications, including retinopathy, proteinuria, neuropathy and macula ...
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Citations
... Evidence suggesting the cost-effectiveness of CSII in type 2 diabetes is scarce. Compared with MDI, CSII was associated with a gain in quality-adjusted life-years ranging between 0.17 and 0.43 and a 15-20% reduction in diabetesrelated complication costs, which mitigated the higher mean lifetime costs [53,54,112]. Sensitivity analyses showed that insulin pump therapy was most cost-effective in individuals with the highest baseline HbA 1c , suggesting that CSII may represent a cost-effective therapeutic alternative for MDItreated type 2 diabetes populations who have HbA 1c levels above target [112]. ...
... Compared with MDI, CSII was associated with a gain in quality-adjusted life-years ranging between 0.17 and 0.43 and a 15-20% reduction in diabetesrelated complication costs, which mitigated the higher mean lifetime costs [53,54,112]. Sensitivity analyses showed that insulin pump therapy was most cost-effective in individuals with the highest baseline HbA 1c , suggesting that CSII may represent a cost-effective therapeutic alternative for MDItreated type 2 diabetes populations who have HbA 1c levels above target [112]. ...
The increasing incidence of type 2 diabetes, which represents 90% of diabetes cases globally, is a major public health concern. Improved glucose management reduces the risk of vascular complications and mortality; however, only a small proportion of the type 2 diabetes population have blood glucose levels within the recommended treatment targets. In recent years, diabetes technologies have revolutionised the care of people with type 1 diabetes, and it is becoming increasingly evident that people with type 2 diabetes can also benefit from these advances. In this review, we describe the current knowledge regarding the role of technologies for people living with type 2 diabetes and the evidence supporting their use in clinical practice. We conclude that continuous glucose monitoring systems deliver glycaemic benefits for individuals with type 2 diabetes, whether treated with insulin or non-insulin therapy; further data are required to evaluate the role of these systems in those with prediabetes (defined as impaired glucose tolerance and/or impaired fasting glucose and/or HbA1c levels between 39 mmol/mol [5.7%] and 47 mmol/mol [6.4%]). The use of insulin pumps seems to be safe and effective in people with type 2 diabetes, especially in those with an HbA1c significantly above target. Initial results from studies exploring the impact of closed-loop systems in type 2 diabetes are promising. We discuss directions for future research to fully understand the potential benefits of integrating evidence-based technology into care for people living with type 2 diabetes and prediabetes.
Graphical Abstract
... Controlling blood glucose levels is crucial to reducing costs and improving the quality of life of people living with DM. Some strategies optimize control, such as multidisciplinary protocols (Henriques et al., 2018), new methods of insulin administration (Roze et al., 2019), new drugs (Durden et al., 2016), telemonitoring of patients (Warren et al., 2018), weight loss and exercising (Karkare et al., 2019), and increasing the number of medical consultations (Schwab et al., 2016). Despite these efforts, without the A1c test, it is difficult to timely identify individuals who are out of their glycemic target and adjust their therapy, which would prevent the advancement of vascular lesions, hospitalizations, and early death. ...
In this book, a particular emphasis, was given to the technological development of new health care/services approaches describing processes regarding the introduction and implementation of technologies into health systems; the knowledge translation; evidence-based policy and its utility as a guide for implementation of health-promoting technologies; big data analytics for health policy in decisions making; and realworld cases.
... For insulin delivery management, a study from Finland published by Roze and colleagues investigating the cost-effectiveness of continuous subcutaneous insulin infusion (CSII) vs MDIs in the OPT2MISE trial using the IQVIA CORE Diabetes Model showed that CSII was associated with a gain in qualityadjusted life expectancy of 0.32 QALYs compared with MDIs (8.15 vs 7.83 QALYs, respectively). 82 In another study, Wahlqvist and colleagues compared the cost-effectiveness of simple insulin infusion devices to MDIs in patients with uncontrolled T2DM in the US based on a simulation model. Simple insulin infusion resulted in 0.17 QALYs gained per patient compared to MDIs, along with lifetime cost savings of $66 883 per person due to reduced insulin use and less complications. ...
Diabetes Mellitus is a global health problem affecting 422 million people worldwide, of which 34.2 million live in the United States alone. Complications due to diabetes can lead to considerable morbidity and mortality related to both micro- and macro- vascular disease. While Hemoglobin A1c testing is the standard test utilized to evaluate glycemic control, emerging targets like "time in range" and "glycemic variability" often provide more accurate assessments of glycemic fluctuations and have implications for diabetes complications and quality of life. Patients with diabetes face considerable burdens of self-care including frequent glucose monitoring, multiple insulin injections, dietary management, and the need to track daily activities, all of which lead to reduced adherence and psychological burn-out. From the provider perspective, limited patient data and access to self-management tools leads to treatment inertia and a reduced ability to help patients achieve and maintain their glycemic goals. In the past few decades, there have been considerable advances in treatment based technology and technological applications designed to help reduce patient burden and provide tools for better self-management. These advances make real-time clinical data available for clinicians to make necessary changes in treatment regimens. In this review, we discuss the latest emerging technologies available for the management of people with type 2 Diabetes Mellitus.
... In the sensitivity analyses carried out in Finland, Literatura optimistic and pessimistic estimates were performed on a set of variables with an impact on investment return. The results suggested that CSII is more economical in patients with higher baseline HbA1c levels (ROZE et al., 2019). On the other hand, in the United Kingdom, the benefit of the use of CSII therapy is for those who have more than two glycemic severe events per year (17.4 events over eight years) and require hospital treatment at least once every eight months due to hypoglycemia symptoms (SCUFFHAM P and CARR L, 2003). ...
... Controlling blood glucose levels is crucial to reducing costs and improving the quality of life of people living with DM. Some strategies optimize control, such as multidisciplinary protocols (Henriques et al., 2018), new methods of insulin administration (Roze et al., 2019), new drugs (Durden et al., 2016), telemonitoring of patients (Warren et al., 2018), weight loss and exercising (Karkare et al., 2019), and increasing the number of medical consultations (Schwab et al., 2016). Despite these efforts, without the A1c test, it is difficult to timely identify individuals who are out of their glycemic target and adjust their therapy, which would prevent the advancement of vascular lesions, hospitalizations, and early death. ...
Objective: We evaluated the cost-effectiveness of the point-of-care A1c (POC-A1c) test device vs. the traditional laboratory dosage in a primary care setting for people living with type 2 diabetes.
Materials and Methods: The Markov model with a 10-year time horizon was based on data from the HealthRise project, in which a group of interventions was implemented to improve diabetes and hypertension control in the primary care network of the urban area of a Brazilian municipality. A POC-A1c device was provided to be used directly in a primary care unit, and for a period of 18 months, 288 patients were included in the point-of-care group, and 1,102 were included in the comparison group. Sensitivity analysis was performed via Monte Carlo simulation and tornado diagram.
Results: The results indicated that the POC-A1c device used in the primary care unit was a cost-effective alternative, which improved access to A1c tests and resulted in an increased rate of early control of blood glucose. In the 10-year period, POC-A1c group presented a mean cost of US9,992.35 and 0.09 for the traditional laboratory test, respectively. The incremental cost was US9,663.20–9,288.28–$10,413.99 and 0.08–0.10 for traditional laboratory test group, at 2.5 and 97.5 percentiles. The costs for nephropathy, retinopathy, and cardiovascular disease and the probability of being hospitalized due to diabetes presented the greatest impact on the model’s result.
Conclusion: This study showed that using POC-A1c devices in primary care settings is a cost-effective alternative for monitoring glycated hemoglobin A1c as a marker of blood glucose control in people living with type 2 diabetes. According to our model, the use of POC-A1c device in a healthcare unit increased the early control of type 2 diabetes and, consequently, reduced the costs of diabetes-related outcomes, in comparison with a centralized laboratory test.
... Furthermore, 40 of the 118 subjects (33.8%) reported having either no significant change in frequency of hypoglyacaemic attacks or more hypoglycaemic attacks after CSII therapy. CSII has been highlighted in several health economic studies as being more cost effective than MDI, at least in adults [18,19], but not in children [20]. In the present study, the common issues encountered by the subjects regarding their medical devices should be reported to the Saudi Food and Drug Administration (SFDA) where approval of such devices takes place. ...
Introduction:
Type 1 diabetes mellitus (T1DM) is on the rise in Saudi Arabia. Management of T1DM is crucial in curbing the economic burden of this disease. Studies on insulin pump issues are scarce in the region. The present study aims to fill this gap.
Methods:
In this single-centre, retrospective study done in King Abdulaziz Medical City (KAMC) from March 2018 to March 2019, a total of 118 known Saudi T1DM adults (34 males and 84 females) were included. Data on demographics, glycated haemoglobin (HbA1c) and CSII use were collected.
Results:
The most common problem encountered by the patients on CSII was breaking down of the pump (30.0%), relocation of the cannula or tubing (22%) and air bubbles affecting delivery (16.1%). Eighty-one subjects (68.6%) claimed to have been admitted for DM management while on CSII. The use of CSII led to a significant reduction in HbA1c in all subjects (p < 0.001), but levels remain suboptimal. Only 53 subjects (44.9%) reported no significant problems in their CSII experience.
Conclusion:
There is a high prevalence of T1DM adult patients experiencing device malfunctions and other issues while on CSII therapy. This may account for suboptimal improvement in the glycaemic control among T1DM Saudi patients. Issues on adherence and device malfunctions should be investigated further.
... In this context, a study developed in Finland, for example, showed that CSII seems to be associated with a higher quality-adjusted life expectancy of 0.32 years of life (QALYs) compared to MDI (8.15 versus 7.83 QALYs,respectively). The average total cost of living was € 15,206 ($ 19,910) higher in the CSII group than in the MDI group € 133,260 ($ 150,000) and € 118,053 ($ 133,000), respectively), resulting in an incremental costeffectiveness ratio (ICER) of € 48,000 ($ 54,000) per QALY earned for CSII versus MDI (Roze et al. 2019). ...
... In this sense, Roze et al. report that the higher treatment costs in the CSII group of their study were partially mitigated by a 15% reduction in complications related to the cost of DM treatment (Roze et al. 2019). Similarly, data suggest that the annual costs of hospitalizations related to severe episodes of hypoglycemia represent high costs in the treatment of diabetic patients. ...
... The use of CSII for patients with the adequate disease control (Colquitt et al. 2004), with few severe hypoglycemic events and well-controlled DM1, may not be economically viable (Scuffham and Carr 2003). The sensitivity analyses performed in Finland have suggested that CSII is more cost-effective in Complimentary Contributor Copy patients with higher baseline HbA1c levels (Roze et al. 2019). In the UK those who benefit most from CSII are those who have more than two severe glycemic events per year (17.4 events over eight years) and require inpatient hospital treatment at least once every eight months because of hypoglycemic pictures (Scuffham and Carr 2003). ...
... Controlling blood glucose levels is crucial to reducing costs and improving the quality of life of people living with DM. Some strategies optimize control, such as multidisciplinary protocols (Henriques et al., 2018), new methods of insulin administration (Roze et al., 2019), new drugs (Durden et al., 2016), telemonitoring of patients (Warren et al., 2018), weight loss and exercising (Karkare et al., 2019), and increasing the number of medical consultations (Schwab et al., 2016). Despite these efforts, without the A1c test, it is difficult to timely identify individuals who are out of their glycemic target and adjust their therapy, which would prevent the advancement of vascular lesions, hospitalizations, and early death. ...
Background: Point-of-care (POC) devices allow to assess HbA1c results in a single visit and facilitates the physicians’ decision making for DM control. This study aimed to assess the cost-effectiveness of POC in comparison to standard laboratory (HPLC method) for HbA1c testing in Brazilian primary care.
Methods: A Markov model was developed in a 10-year time horizon for the perspective of the public health system. Effectiveness was assessed by the rate of HbA1c control after 6-months follow-up. Data were obtained from an ongoing cohort. Controlled and uncontrolled subjects were included in transition states for negative outcomes (cardiovascular diseases and complications). Probabilities and costs of transition states were extracted from a literature review.
Results: Estimated annual cost for patients monitored by HPLC was U.S. 5,960.64 (SD 2,514.00) and 0.91, respectively. The evolution of the net monetary benefit is presented in the chart below.
Conclusions: HbA1c tested by POC appears to be cost-effective in comparison with laboratory testing to improve glycemic control and prevent DM-related cardiovascular diseases and complications.
Disclosure
D.S. Medeiros: None. L.S. Rosa: None. S. Mistro: None. C.N. Kochergin: None. D.A. Soares: None. K.O. Silva: None. J.A. Louzado: None. M.L. Cortes: None. V.M. Bezerra: None. W.W. Amorim: None. M.G. Oliveira: None.
Funding
Medtronic Foundation
The use of continuous subcutaneous insulin infusion delivery via insulin pumps is today considered standard of care for type 1 diabetes (T1D). Closed-loop systems combining continuous glucose monitoring (CGM) with automated algorithm-driven insulin delivery have been shown to be safe and efficacious in randomized controlled studies and in real-life studies in both pediatric and adult individuals with T1D. Implementation of hybrid closed-loop (HCL) systems have shown incremental effectiveness with further reduction of hypoglycemia and hyperglycemia. Although less extensively studied in type 2 diabetes (T2D), insulin pumps have demonstrated their effectiveness on glucose control together with the reduction in insulin needs and a neutral effect on weight. Recent studies have also shown promising results with the use of HCL in T2D. Cost-effectiveness studies both in T1D and T2D have shown that pump is cost effective in several countries, leading to improvements in quality adjusted life years. Insulin pumps are currently reimbursed for T1D in many European countries, but only in a few for individuals with T2D. HCL systems are to be evaluated in future trials performed in T2D to compare their incremental efficacy and cost effectiveness in comparison with available intensification tools which include multiple daily insulin injections, metformin, SGLT-2 inhibitors and GLP-1 receptor agonists. There is a need for updated guidelines for the use of CSII and HCL in individuals living with T2D based on the emerging evidence, identifying, and recommending for the people who'd benefit the most, which would eventually form a basis for the reimbursement and health policies. This article is protected by copyright. All rights reserved.
