Clinical effectiveness and cost-effectiveness of continuous subcutaneous insulin infusion for diabetes: systematic review and economic evaluation

Perioperative Insulin Pump Therapy Decreases Readmission Risk and Improves Outcomes in Patients with Diabetes

OBJECTIVE

To evaluate the impact of temporary insulin pump use during hospitalization on glycemia, postoperative complications, and cost/utilization in perioperative patients with diabetes.

METHODS

Patients (n=159) with type 2 diabetes and hospitalized for elective surgery were recruited from three hospitals. Subjects were categorized into the insulin pump group and the multiple daily subcutaneous insulin injection group according to their treatment therapy. Data were collected at admission, discharge, and 3 months post-discharge.

RESULTS

Subjects in the CSII group who were still on insulin therapy transitioned from CSII to MDII; however, their daily insulin dosages were lower than those in the MDII group (15.31±10.98 U/d vs. 23.48±17.02 U/d, P=0.015) after discharge. In terms of medical costs, the CSII group had significantly higher hospitalization costs than the MDII group (112.36±103.43 thousand RMB vs. 82.65±77.98 thousand RMB, P=0.043). After 3 months, the CSII group had significantly lower outpatient costs than the MDII group (3.17±0.94 thousand RMB vs. 3.98±1.76 thousand RMB, P ˂ 0.001). In the MDII group, 10 patients reported severe postoperative complications requiring re-hospitalization; there were no similar reports in the CSII group.

CONCLUSION

Temporary use of insulin pump therapy for perioperative patients with diabetes results in a reduction in blood glucose and blood glucose fluctuation during hospitalization, HbA1c, and the risk of postoperative complication and readmission, thus significantly decreasing costs in this complex patient cohort. Further work is needed to better understand indications for utilizing pump therapy based on diabetes phenotype and the complexity of planned surgical intervention.

A cluster randomised controlled trial, process and economic evaluation of quality improvement collaboratives aligned to a national audit to improve the care for people with diabetes (EQUIPD): study protocol

BACKGROUND

People with type 1 diabetes and raised glucose levels are at greater risk of retinopathy, nephropathy, neuropathy, cardiovascular disease, sexual health problems and foot disease. The UK National Institute for Health and Care Excellence (NICE) recommends continuous subcutaneous 'insulin pump' therapy for people with type 1 diabetes whose HbA1c is above 69 mmol/mol. Insulin pump use can improve quality of life, cut cardiovascular risk and increase treatment satisfaction. About 90,000 people in England and Wales meet NICE criteria for insulin pumps but do not use one. Insulin pump use also varies markedly by deprivation, ethnicity, sex and location. Increasing insulin pump use is a key improvement priority. Audit and feedback is a common but variably effective intervention. Limited capabilities of healthcare providers to mount effective responses to feedback from national audits, such as the National Diabetes Audit (NDA), undermines efforts to improve care. We have co-developed a theoretically and empirically informed quality improvement collaborative (QIC) to strengthen local responses to feedback with patients and carers, national audits and healthcare providers. We will evaluate whether the QIC improves the uptake of insulin pumps following NDA feedback.

METHODS

We will undertake an efficient cluster randomised trial using routine data. The QIC will be delivered alongside the NDA to specialist diabetes teams in England and Wales. Our primary outcome will be the proportion of people with type 1 diabetes and an HbA1c above 69 mmol/mol who start and continue insulin pump use during the 18-month intervention period. Secondary outcomes will assess change in glucose control and duration of pump use. Subgroup analyses will explore impacts upon inequalities by ethnicity, sex, age and deprivation. A theory-informed process evaluation will explore diabetes specialist teams' engagement, implementation, fidelity and tailoring through observations, interviews, surveys and documentary analysis. An economic evaluation will micro-cost the QIC, estimate cost-effectiveness of NDA feedback with QIC and estimate the budget impact of NHS-wide QIC roll out.

DISCUSSION

Our study responds to a need for more head-to-head trials of different ways of reinforcing feedback delivery. Our findings will have implications for other large-scale audit and feedback programmes.

TRIAL REGISTRATION

ISRCTN82176651 Registered 18 October 2022.

Cost-effectiveness of the tubeless automated insulin delivery system vs standard of care in the management of type 1 diabetes in the United States

BACKGROUND: A tubeless, on-body automated insulin delivery (AID) system (Omnipod 5 Automated Insulin Delivery System) demonstrated improved glycated hemoglobin A1c levels and increased time in range (70 mg/dL to 180 mg/dL) for both adults and children with type 1 diabetes in a 13-week multicenter, single-arm study. OBJECTIVE: To assess the cost-effectiveness of the tubeless AID system compared with standard of care (SoC) in the management of type 1 diabetes (T1D) in the United States. METHODS: Cost-effectiveness analyses were conducted from a US payer's perspective, using the IQVIA Core Diabetes Model (version 9.5), with a time horizon of 60 years and an annual discount of 3.0% on both costs and effects. Simulated patients received either tubeless AID or SoC, the latter being defined as either continuous subcutaneous insulin infusion (86% of patients) or multiple daily injections. Two cohorts (children: <18 years; adults: ≥18 years) of patients with T1D and 2 thresholds for nonsevere hypoglycemia (nonsevere hypoglycemia event [NSHE] <54 mg/dL and <70 mg/dL) were considered. Baseline cohort characteristics and treatment effects of different risk factors for tubeless AID were sourced from the clinical trial. Utilities and cost of diabetes-related complications were obtained from published sources. Treatment costs were derived from US national database sources. Scenario analyses and probabilistic sensitivity analyses were performed to test the robustness of the results. RESULTS: Treating children with T1D with tubeless AID, considering an NSHE threshold of less than 54 mg/dL, brings incremental life-years (1.375) and quality-adjusted life-years (QALYs) (1.521) at an incremental cost of $15,099 compared with SoC, resulting in an incremental cost-effectiveness ratio of $9,927 per QALY gained. Similar results were obtained for adults with T1D assuming an NSHE threshold of less than 54 mg/dL (incremental cost-effectiveness ratio = $10,310 per QALY gained). Furthermore, tubeless AID is a dominant treatment option for children and adults with T1D assuming an NSHE threshold of less than 70 mg/dL compared with SoC. The probabilistic sensitivity analyses results showed that compared with SoC, in both children and adults with T1D, tubeless AID was cost-effective in more than 90% of simulations, assuming a willingness-to-pay threshold of $100,000 per QALY gained. The key drivers of the model were the cost of ketoacidosis, duration of treatment effect, threshold of NSHE, and definition of severe hypoglycemia. CONCLUSIONS: The current analyses suggest that the tubeless AID system can be considered a cost-effective treatment compared with SoC in people with T1D from a US payer's perspective. DISCLOSURES: This research was funded by Insulet. Mr Hopley, Ms Boyd, and Mr Swift are full-time Insulet employees and own stock in Insulet Corporation. IQVIA, the employer of Ms Ramos and Dr Lamotte, received consulting fees for this work. Dr Biskupiak is receiving research support and consulting fees from Insulet. Dr Brixner has received consulting fees from Insulet. The University of Utah has received research funding from Insulet. Dr Levy is a consultant with Dexcom and Eli Lilly and has received grant/research support from Insulet, Tandem, Dexcom, and Abbott Diabetes. Dr Forlenza conducted research sponsored by Medtronic, Dexcom, Abbott, Tandem, Insulet, Beta Bionics, and Lilly. He has been speaker/consultant/advisory board member for Medtronic, Dexcom, Abbott, Tandem, Insulet, Beta Bionics, and Lilly.

Prevalence of and reasons for discontinuation of continuous subcutaneous insulin infusion in people with type 1 diabetes: a systematic review

INTRODUCTION

The introduction of CSII in clinical care has led to more optimal glycemic and quality of life outcomes, compared with MDI. Despite this, some insulin pump users revert back to MDI. The aim of this review was to include the most recent rates of insulin pump discontinuation among people with type 1 diabetes and to identify reasons for and factors associated with discontinuation.

MATERIALS AND METHODS

A systematic literature search was conducted using the Embase.com, MEDLINE (via OVID), PsycINFO and CINAHL databases. Titles and abstracts of eligible publications were screened and baseline characteristics of the included studies were extracted, as were variables in the context of insulin pump. Data were synthesized into themes: indications for insulin pump initiation, PWD-reported reasons for and factors associated with insulin pump discontinuation.

RESULTS

A total of 826 eligible publications were identified and 67 were included. Discontinuation percentages ranged from 0% to 30% (median 7%). The most frequently mentioned reasons for discontinuing were wear-related issues (e.g. device attached to the body, interference with daily activities, discomfort, affected body image). Related factors included HbA1c (17%), issues with following treatment recommendations (14%), age (11%), gender (9%), side-effects (7%), comorbidity- and complication-related factors (6%).

CONCLUSIONS

Despite many developments in technology insulin pump, discontinuation rates and PWD-reported reasons for and factors associated with insulin pump discontinuation in more recent studies were not that different from earlier reviews/meta-analyses. Successful insulin pump treatment depends on a knowledgeable and willing HCP team and a close match with PWDs wishes and needs.

Effectiveness of educational and behavioural interventions for reducing fear of hypoglycaemia among adults with type 1 diabetes: Systematic review and meta-analyses

AIMS

To summarize and critically appraise evidence regarding the effectiveness of educational and/or behavioural interventions in reducing fear of hypoglycaemia among adults with type 1 diabetes.

METHODS

Systematic searches of medical and psychology databases were conducted. Risk-of-bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools. Data were synthesized using random-effects meta-analyses for randomized controlled trials (RCTs) and narrative synthesis for observational studies.

RESULTS

Five RCTs (N = 682) and seven observational studies (N = 1519) met the inclusion criteria, reporting on behavioural, structured education and cognitive-behavioural therapy (CBT) interventions. Most studies assessed fear of hypoglycaemia using the Hypoglycaemia Fear Survey Worry (HFS-W) and Behaviour (HFS-B) subscales. Mean fear of hypoglycaemia at baseline was relatively low across studies. Meta-analyses showed a significant effect of interventions on HFS-W (SMD = -0.17, p = 0.032) but not on HFS-B scores (SMD = -0.34, p = 0.113). Across RCTs, Blood Glucose Awareness Training (BGAT) had the largest effect on HFS-W and HFS-B scores, and one CBT-based program was as effective as BGAT in reducing HFS-B scores. Observational studies showed that Dose Adjustment for Normal Eating (DAFNE) was associated with significant fear of hypoglycaemia reductions.

CONCLUSIONS

Current evidence suggests that educational and behavioural interventions can reduce fear of hypoglycaemia. However, no study to date has examined these interventions among people with high fear of hypoglycaemia.

Quantitative and qualitative analysis of the quality of life of Type 1 diabetes patients using insulin pumps and of those receiving multiple daily insulin injections

Introduction

Insulin pump therapy represents an alternative to multiple daily injections and can improve glycemic control and quality of life (QoL) in Type 1 diabetes mellitus (T1DM) patients. We aimed to explore the differences and factors related to the T1DM-specific QoL of such patients in Latvia.

Design and methods

A mixed-method cross-sectional study on 87 adult T1DM patients included 20 pump users and 67 users of injections who participated in the quantitative part of the study; 8 pump users and 13 injection users participated in the qualitative part. Patients were invited to participate using a dedicated digital platform. Their QoL and self-management habits were assessed using specially developed questionnaires adapted to Latvian conditions. Multiple logistic regression models were built to investigate the association between social and self-management factors and patients’ QoL. In addition, qualitative analysis of answers was performed.

Results

Insulin pump users were younger, had higher incomes, and reported higher T1DM expenses than users of multiple daily injections. There were no differences in self-management between the groups; Total QoL differed at the 0.1 significance level. In fully adjusted multiple logistic regression models, the most important factor that increased Total QoL was lower T1DM-related expenses (odds ratio, OR 7.02 [95% confidence interval 1.29; 38.0]). Men and those with more years of living with T1DM had better QoL (OR 9.62 [2.20; 42.1] and OR 1.16 [1.05; 1.29], respectively), but the method of administration was not significantly associated with QoL (OR 7.38 [0.87; 62.9]). Qualitative data supported the results of quantitative analysis.

Conclusions

QoL was the main reason to use an insulin pump, while the expense was the main reason to avoid the use of it or to stop using it. Reimbursement policies thus should be considered to enable patients to choose the more convenient method for themselves.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02029-2.

Cost-effectiveness analysis of continuous subcutaneous insulin infusion versus multiple daily insulin for treatment of children with type 1 diabetes

OBJECTIVE

To evaluate the health economics of using continuous subcutaneous insulin infusion (CSII) therapy versus multiple daily injections (MDI) therapy in children and adolescent patients with type 1 diabetes (T1D) in Qingdao, China.

METHODS

A long-term cost-effectiveness analysis was conducted using the IQVIA Core Diabetes Model (CDM). The baseline characteristics of the simulated cohorts were obtained from 213 pediatric T1D patients who received care with CSII(104 cases) or MDI(109 cases) in Qingdao from 1 January 2015 to 31 March 2019. In the essential case, the expenditure of the complications and treatment of the disease with both therapies were evaluated in Chinese currency from the perspective of healthcare system. In a secondary analysis, the model used a 70-year time horizon, and a discount rate of 5% was applied to all future health outcomes and costs. A one-way sensitivity analysis was conducted on delta HbA1c, different prices of insulin pump, price of each upgrade cycle rates and different discount rates. Uncertainty was also evaluated by the probability sensitivity analysis and scenario analysis.

RESULTS

In the base-case analysis, the lifetime total costs were lower for CSII group at ¥630,871 per patient compared with ¥672,672 for MDI group. The quality-adjusted life years (QALYs) gained were 11.612 and 11.197 for patients treated with CSII group and MDI group, respectively. The CSII group was cost-saving compared to MDI group. The feasibility of CSII group being cost-effective was 100% under the threshold of 3 times per capita GDP of China in 2019 (¥212,676) which was indicated from the probabilistic sensitivity analysis. Regarding scenario analysis, the ICER of the CSII group compared to MDI was between -151,583 and 153,366 RMB/QALYs, which is cost-effective.

CONCLUSIONS

This economic evaluation compared CSII therapy versus MDI therapy for T1D children and adolescent patients in China and findings indicate that CSII should be considered a preferred treatment modality to MDI.

Chinese clinical practice guidelines for perioperative blood glucose management

With the increased incidence of diabetes, the number of diabetic patients who require surgical treatment is also increasing. Unfortunately, practices in this area lack standardisation. The purpose of this multidisciplinary, evidence-based guidelines for perioperative blood glucose management is to provide a comprehensive set of recommendations for clinicians treating diabetes with different types of surgery. The intended audience comprises Chinese endocrinologists, surgeons, anaesthetists, clinical pharmacists, nurses and professionals involved in perioperative blood glucose management. The guidelines were formulated as follows. First, a multidisciplinary expert group was established to identify and formulate key research questions on topics of priority according to the Population, Intervention, Comparator and Outcomes (PICO) process. We conducted a meta-analysis of available studies using Review Manager version 5.3, as appropriate. We pooled crude estimates as odds ratios with 95% confidence intervals using a random-effects model, and used the Grading of Recommendations Assessment, Development, and Evaluation methods to assess the quality of the retrieved evidence. Finally, 32 recommendations were gathered that covered 11 fields-management and coordination, endocrinologists' consultation, diabetes diagnosis, surgery timing and anaesthesia method, blood glucose target values and monitoring frequency, hypoglycaemia treatment, oral administration of blood glucose lowering drugs, use of insulin, enteral and parenteral nutritional, postoperative treatment and medication and education and training. Twenty-five systematic reviews and meta-analyses were conducted for these guidelines to address the PICO questions. These guidelines are intended to improve perioperative blood glucose management and help doctors in specifying medical diagnosis and treatment, and will be implemented / disseminated extensively in China.

Barriers and facilitators to accessing insulin pump therapy by adults with type 1 diabetes mellitus: a qualitative study

AIMS

Uptake of continuous subcutaneous insulin infusion (CSII) by people with diabetes (PwD) in Ireland is low and exhibits regional variation. This study explores barriers and facilitators to accessing CSII by adults with Type 1 diabetes mellitus.

RESEARCH DESIGN AND METHODS

A qualitative study employing focus groups with adults with Type 1 diabetes mellitus (n = 26) and semi-structured interviews with health care professionals (HCP) and other key stakeholders (n = 21) was conducted. Reflexive thematic analysis was used to analyze data, using NVivo.

RESULTS

Four main themes comprising barriers to or facilitators of CSII uptake were identified. These included: (1) awareness of CSII and its benefits, (2) the structure of diabetes services, (3) the capacity of the diabetes service to deliver the CSII service, and (4) the impact of individuals' attitudes and personal characteristics-both PwD, and HCP. Each of these themes was associated with a number of categories, of which 18 were identified and explored. If the structure of the health-service is insufficient and capacity is poor (e.g., under-resourced clinics), CSII uptake appears to be impacted by individuals': interest, attitude, willingness and motivation, which may intensify the regional inequality in accessing CSII.

CONCLUSIONS

This study identified factors that contribute to gaps in the delivery of diabetes care that policy-makers may use to improve access to CSII for adult PwD.

The improved survival rate and cost-effectiveness of a 7-day continuous subcutaneous insulin infusion set

AIMS

The purpose of this article is to compare the insulin cost-savings of the Medtronic Extended Infusion Set (or EIS, a.k.a. Extended Wear Infusion Set) designed and labeled for up to 7-day use with rapid-acting insulins to the current standard of care, 2- to 3-day infusion sets.

METHODS

There are three major improvements (reducing insulin waste, plastic waste, and adverse events) with the extended duration of infusion set wear. This analysis focuses on cost savings from reduced insulin wastage during set changes. Studies published on insulin infusion set survival and EIS clinical trial data (NCT04113694) were used to estimate device lifetime performance using a Markov chain Monte Carlo model, including the assessment of adverse effects and device failure. Total costs associated with infusion set change or failure were systematically found in published literature or estimated based on physical usage, and the direct impact on insulin costs was calculated.

RESULTS

Based on the model and clinical data, EIS users can expect to change their infusion sets about 75 fewer times than standard set users each year. The costs related to unrecoverable insulin during an infusion set and reservoir change in the US were estimated to range from $19.79 to $22.48, resulting in approximately $1324 to $1677 in annual cost-savings for the typical user from minimizing insulin wastage.

LIMITATIONS

The study only assessed devices used within a monitored setting, that is, clinical trials. In addition, the variability associated with healthcare standards and costs and individual treatment variability including insulin dosages, contribute to the uncertainties with the calculations.

CONCLUSIONS

Our analysis demonstrates that by extending the duration of infusion set wear, there may be substantial cost savings by reducing insulin wastage.

Glycaemia and utilisation of technology across the lifespan of adults with type 1 diabetes: Results of the Australian National Diabetes Audit (ANDA)

AIMS

To evaluate the utilisation of technologies and associated glycaemia among adults with type 1 diabetes.

METHODS

De-identified data from adults with type 1 diabetes (≥18 years old) in the Australian National Diabetes Audit (ANDA)-2019 were analysed. Proportions using insulin pumps or injections with continuous glucose monitoring (CGM) or capillary-glucose testing were compared. Technology use among adults was compared to young people (<21 years old) with subsidised CGM. Glycaemia and complication-burden were assessed across management strategies.

RESULTS

1,693 adults were analysed. Mean(±SD) age, diabetes duration, and HbA1c were 43.3 ± 17.0 years, 20.3 ± 14.3 years and 8.4% ± 1.7 [68 ± 19 mmol/mol], respectively. Among adults, 40% used at least one device, 27% used insulin pumps, and 23% used CGM. CGM was used by 62% of young people with subsidised access. Mean HbA1c was consistently lower among adults using CGM, insulin pumps, or combined insulin pump and CGM compared to standard care (8.3% ± 1.6 [67 ± 18 mmol/mol], 8.2% ± 1.4 [66 ± 15 mmol/mol], and 7.8% ± 1.4 [62 ± 15 mmol/mol] respectively compared to 8.6% ± 1.8 [70 ± 20 mmol/mol], p < 0.001). Technology use was not associated with diabetic ketoacidosis but CGM was associated with more hypoglycaemia.

CONCLUSIONS

Government subsidy is an important consideration for utilisation of technologies among adults with type 1 diabetes. Technology use across the adult lifespan was associated with lower HbA1c than insulin injections and capillary-glucose testing.

A multi-center randomized controlled trial of the LenoMed ATA-I-1-0 insulin pump for the intensive treatment of diabetic patients

Background

Continuous subcutaneous insulin infusion (CSII) is an effective method for managing diabetes. The aim of this study was to evaluate the efficacy and safety of the LenoMed ATA-I-1-0 insulin pump for the treatment of patients with type 1 and type 2 diabetes, compared to the Medtronic MMT-712 insulin pump.

Methods

A total of 120 subjects with diabetes needing insulin treatment were recruited, and 104 completed the trial. The intervention and control group used the LenoMed and Medtronic insulin pump, respectively. The primary outcome was a reduction in fasting plasma glucose. Secondary outcomes included blood glucose control at 7 time points (before and after each meal, and before sleep), hemoglobin A1c (HbA1c) levels at 1 time point, and accuracy and safety of the pumps.

Results

In the per protocol set of 104 subjects, a significant drop in fasting plasma glucose levels was observed for 98.0% subjects in the intervention group and 92.7% in the control group. There was no statistically significant difference between groups [5.23%; 95% confidence interval (CI): −2.69% –13.2%]. Compared to baseline, levels of blood glucose and HbA1c dropped (P<0.001) at a similar magnitude in both groups. The accuracy and alarm effectiveness was 100%. No adverse event or severe adverse event related to the medication occurred in the study.

Conclusions

The novel injection equipment, the LenoMed ATA-I-1-0 insulin pump, demonstrated efficacy and a good safety profile, and was not inferior to the widely used Medtronic MMT-712 insulin pump. Thus, our study suggests that the LenoMed ATA-I-1-0 insulin pump can be widely used in clinical practice.

Cost-effectiveness of health technologies in adults with type 1 diabetes: a systematic review and narrative synthesis

BACKGROUND

With the rapid development of technologies for type 1 diabetes, economic evaluations are integral in guiding cost-effective clinical and policy decisions. We therefore aimed to review and synthesise the current economic literature for available diabetes management technologies and outline key determinants of cost-effectiveness.

METHODS

A systematic search was conducted in April 2019 that focused on modelling or trial based economic evaluations. Searched databases included Medline, Medline in-process and other non-indexed citations, EMBASE, PubMed, All Evidenced Based Medicine Reviews, EconLit, Cost-effectiveness analysis Registry, Research Papers in Economics, Web of Science, PsycInfo, CINAHL, and PROSPERO from inception. We assessed quality of included studies with the Questionnaire to Assess Relevance and Credibility of Modeling Studies for Informing Health Care Decision Making an ISPOR-AMCP-NPC good practice task force report. Screening of abstracts and full-texts, appraisal, and extraction were performed by two independent researches.

RESULTS

We identified 16,772 publications, of which 35 were analysed and included 11 health technologies. Despite a lack of consensus, most studies reported that insulin pumps (56%) or interstitial glucose sensors (62%) were cost-effective, although incremental cost-effectiveness ratios ranged widely ($14,266-$2,997,832 USD). Cost-effectiveness for combined insulin pumps and glucose sensors was less clear. Determinants of cost-effectiveness included treatment effects on glycosylated haemoglobin and hypoglycaemia, costing of technologies and complications, and measures of utility.

CONCLUSIONS

Insulin pumps or glucose sensors appeared cost-effective, particularly in populations with higher HbA1c levels and rates of hypoglycaemia. However, cost-effectiveness for combined insulin pumps and glucose sensors was less clear.

REGISTRATION

The study was registered with PROSPERO, number CRD42017077221.

Artificial Pancreas Control Strategies Used for Type 1 Diabetes Control and Treatment: A Comprehensive Analysis

This paper presents a comprehensive survey about the fundamental components of the artificial pancreas (AP) system including insulin administration and delivery, glucose measurement (GM), and control strategies/algorithms used for type 1 diabetes mellitus (T1DM) treatment and control. Our main focus is on the T1DM that emerges due to pancreas’s failure to produce sufficient insulin due to the loss of beta cells (β-cells). We discuss various insulin administration and delivery methods including physiological methods, open-loop, and closed-loop schemes. Furthermore, we report several factors such as hyperglycemia, hypoglycemia, and many other physical factors that need to be considered while infusing insulin in human body via AP systems. We discuss three prominent control algorithms including proportional-integral- derivative (PID), fuzzy logic, and model predictive, which have been clinically evaluated and have all shown promising results. In addition, linear and non-linear insulin infusion control schemes have been formally discussed. To the best of our knowledge, this is the first work which systematically covers recent developments in the AP components with a solid foundation for future studies in the T1DM field.

Availability of and access to continuous subcutaneous insulin infusion therapy for adults with type 1 diabetes in Ireland

AIMS

The uptake of continuous subcutaneous insulin infusion (CSII) is low in adults with type 1 diabetes mellitus (T1DM) in Ireland, compared to other countries where CSII is reimbursed. To explore the reasons for the low uptake, this study aims to investigate the availability of CSII in adult diabetes clinics in Ireland.

METHODS

A national survey of all adult diabetes clinics (public and private) in Ireland was conducted and completed anonymously by the lead physician/diabetes nurse specialist in each clinic. Descriptive statistics and comparisons between clinics offering different levels of care for CSII are presented.

RESULTS

Of 50 diabetes clinics invited, 47 (94%) participated in the study. Fifteen clinics (32%) offered no support for CSII, while 21 (45%) reported offering both training to commence CSII and ongoing support. Based on the survey findings, access to CSII was unavailable for 2426 (11%) of those with T1DM. The majority (n = 15,831, 71% of 22,321 T1DM population) received diabetes care from clinics offering CSII training, but only 2165 were using CSII (10% of T1DM population). Uptake of CSII was higher in clinics offering training than in those offering follow-up care for CSII only (12% vs. 5%, p < 0.001). Clinics offering all CSII services had more specialists (p = 0.005 for endocrinologists and p < 0.001 for dietitians). Reasons for not offering CSII services included staff shortages and heavy workload.

CONCLUSIONS

This study highlights the low uptake of CSII in Ireland and demonstrates that, even when reimbursed, other barriers to uptake of CSII can limit its use.

Low uptake of continuous subcutaneous insulin infusion therapy in people with type 1 diabetes in Ireland: a retrospective cross-sectional study

BACKGROUND

The uptake of continuous subcutaneous insulin infusion (CSII) therapy in those with type 1 diabetes varies internationally and is mainly determined by the national healthcare reimbursement systems. The aim of this study is to estimate national and regional uptake of CSII therapy in children, adolescents and adults with type 1 diabetes in Ireland.

METHODS

A retrospective cross-sectional study was conducted utilizing the national pharmacy claims database in 2016. Individuals using CSII were identified by dispensing of infusion sets. The uptake of CSII was calculated as the percentage of people with type 1 diabetes claiming CSII sets in 2016, both in children and adolescent (age < 18 years) and adult populations (≥ 18 years). Descriptive statistics including percentages with 95% confidence intervals (CIs) are presented, stratified by age-groups and geographical regions, and chi-square tests used for comparisons.

RESULTS

Of 20,081 people with type 1 diabetes, 2111 (10.5, 95% CI: 10.1-10.9%) were using CSII in 2016. Uptake was five-fold higher in children and adolescents at 34.7% (95% CI: 32.9-36.5%) than in adults at 6.8% (95% CI: 6.4-7.2%). Significant geographical heterogeneity in CSII uptake was found, from 12.6 to 53.7% in children and adolescents (p < 0.001), and 2 to 9.6% in adults (p < 0.001).

CONCLUSIONS

Uptake of CSII in people with type 1 diabetes is low in Ireland, particularly in those ≥18 years. Identification of barriers to uptake, particularly in this group, is required.

The Efficacy of Technology in Type 1 Diabetes: A Systematic Review, Network Meta-analysis, and Narrative Synthesis

Background: Existing technologies for type 1 diabetes have not been compared against the full range of alternative devices. Multiple metrics of glycemia and patient-reported outcomes for evaluating technologies also require consideration. We thus conducted a systematic review, network meta-analysis, and narrative synthesis to compare the relative efficacy of available technologies for the management of type 1 diabetes. Methods: We searched MEDLINE, MEDLINE In-Process and other nonindexed citations, EMBASE, PubMed, All Evidence-Based Medicine Reviews, Web of Science, PsycINFO, CINAHL, and PROSPERO (inception-April 24, 2019). We included RCT ≥6 weeks duration comparing technologies for type 1 diabetes management among nonpregnant adults (>18 years of age). Data were extracted using a predefined tool. Primary outcomes were A1c (%), hypoglycemia rates, and quality of life (QoL). We estimated mean difference for A1c and nonsevere hypoglycemia, rate ratio for severe hypoglycemia, and standardized mean difference for QoL in network meta-analysis with random effects. Results: We identified 16,772 publications, of which 52 eligible studies compared 12 diabetes management technologies comprising 3,975 participants in network meta-analysis. Integrated insulin pump and continuous glucose monitoring (CGM) systems with low-glucose suspend or hybrid closed-loop algorithms resulted in A1c levels 0.96% (predictive interval [95% PrI] 0.04-1.89) and 0.87% (95% PrI 0.12-1.63) lower than multiple daily injections with either flash glucose monitoring or capillary glucose testing, respectively. In addition, integrated systems had the best ranking for A1c reduction utilizing the surface under the cumulative ranking curve (SUCRA-96.4). While treatment effects were nonsignificant for many technology comparisons regarding severe hypoglycemia and QoL, simultaneous evaluation of outcomes in cluster analyses as well as narrative synthesis appeared to favor integrated insulin pump and continuous glucose monitors. Overall risk of bias was moderate-high. Certainty of evidence was very low. Conclusions: Integrated insulin pump and CGM systems with low-glucose suspend or hybrid closed-loop capability appeared best for A1c reduction, composite ranking for A1c and severe hypoglycemia, and possibly QoL. Registration: PROSPERO, number CRD42017077221.

Continuous subcutaneous insulin infusion reduces the risk of postoperative infection

BACKGROUND

Perioperative hyperglycemia was associated with postoperative infection, and proper management of perioperative glucose has become critical in improving the prognosis of patients.

METHODS

A total of 1015 diabetic patients who underwent surgery and received insulin treatment for their hyperglycemia in our hospital were retrospectively reviewed. According to propensity matching, we obtained 253 pairs of patients from the group which received continuous subcutaneous insulin infusion (CSII) therapy (CSII group) and the group which received insulin injection therapy (non-CSII group). Perioperative glucose levels and corresponding outcomes were compared between the two groups.

RESULTS

Compared with the non-CSII group, the CSII group had lower fasting and mean glucose levels, lower incidence of fever (operation day: 18.6% vs 10.2%; P = .014; first postoperative day: 55.1% vs 34.7%; P < .001), a positive rate of postoperative secretion culture (6.3% vs 1.2%; P = .004), and a shorter time of antibiotics use (total antibiotics use: P = .002; postoperative antibiotics use: P < .001) and hospital stays (P < .001). However, there was no difference in the total medical expenditure between the two groups (P = .499). Further analysis showed that CSII therapy was superior to multiple daily insulin injection (MDI) therapy in its effect on infection and other postoperative outcomes when 64 pairs of patients from the CSII group and MDI group were compared.

CONCLUSIONS

CSII therapy provides better perioperative glucose control and a lower risk of postoperative infection without increasing the total medical expenditure.

The Development and Psychometric Validation of the Diabetes Impact and Device Satisfaction Scale for Individuals with Type 1 Diabetes

BACKGROUND

With the rapid development of new insulin delivery technology, measuring patient experience has become especially pertinent. The current study reports on item development, psychometric validation, and intended use of the newly developed Diabetes Impact and Device Satisfaction (DIDS) Scale.

METHOD

The DIDS Scale was informed by a comprehensive literature review, and field tested as part of two focus groups. The finalized measure was used at baseline and 6 months post-assessment with a large US cohort. Exploratory factor analyses (EFAs) were conducted to determine and confirm factor structure and item selection. Internal reliability, test-retest reliability, and convergent/divergent validity of the emerged factors were tested with demographics, diabetes-specific information, and diabetes behavioral and satisfaction measures.

RESULTS

In all, 778 participants with type 1 diabetes (66% female, mean age 47.13 ± 17.76 years, 74% insulin pump users) completed surveys at both baseline and post-assessment. EFA highlighted two factors-Device Satisfaction (seven items, Cronbach's α = 0.85-0.90) and Diabetes Impact (four items, Cronbach's α = 0.71-0.75). DIDS Scale demonstrated good concurrent validity and test-retest reliability.

CONCLUSION

The DIDS Scale is a novel and a brief assessment tool with robust psychometric properties. It is recommended for use across all insulin delivery devices and is considered appropriate for use in longitudinal studies. Future studies are recommended to evaluate the performance of DIDS Scale in diverse populations with diabetes.

Pregnancy outcomes among women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion versus multiple daily injections: A retrospective cohort study

Background

Insulin delivery options for pregnant women with type 1 diabetes mellitus are either continuous subcutaneous insulin infusion or multiple daily injections. The aim of this paper is to compare pregnancy outcomes in women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion or multiple daily injections in pregnancy.

Methods

Retrospective single-centre cohort study of 298 pregnancies booked between 2006 and 2016. Descriptive analysis was performed for HbA1c values. Logistic regression models were created to compare selected maternal and neonatal outcomes.

Results

Continuous subcutaneous insulin infusion was associated with increased risk of large-for-gestational age (aOR 2.00, 95% CI 1.20-3.34) and preterm neonates (aOR 1.80, 95% CI 1.04-3.03). Continuous subcutaneous insulin infusion had no association with increased risk of adverse pregnancy outcomes. No difference in HbA1c values existed between groups.

Conclusion

Using continuous subcutaneous insulin infusion for type 1 diabetes mellitus through pregnancy is associated with increased risk of large-for-gestational age and preterm neonates, without increased risk of associated adverse maternal or neonatal outcomes.

[Insulin pump therapy in children, adolescents and adults, guidelines (Update 2019)]

This position statement is based on current evidence available on the safety and benefits of continuous subcutaneous insulin infusion therapy (CSII, pump therapy) in diabetes with an emphasis on the effects of CSII on glycemic control, hypoglycaemia rates, occurrence of ketoacidosis, quality of life and the use of insulin pump therapy in pregnancy. The current article represents the recommendations of the Austrian Diabetes Association for the clinical praxis of insulin pump treatment in children, adolescents and adults.

Cost-effectiveness of the use of the continuous subcutaneous insulin infusion pump versus daily multiple injections in type 1 diabetes adult patients at the Mexican Institute of Social Security

Background

To estimate the incremental cost-effectiveness ratio (ICER) of the use of continuous subcutaneous insulin infusion (CSII) therapy versus multiple daily injections (MDI) therapy in adult patients with type 1 diabetes (T1D) at the Mexican Institute of Social Security (IMSS).

Methods

An analysis was developed using the internationally validated Core Diabetes Model (CDM) with which the incidence and progression of acute and chronic complications and the mortality of T1D was simulated throughout life. The baseline characteristics of the simulated cohorts were obtained from Mexican T1D adult patients aged ≥ 18 years that received care at two national IMSS medical centres in 2016. In the base case, the costs of the complications and treatment of the disease with both therapies were estimated in Mexican currency from the perspective of the institution, using Diagnosis Related Groups for outpatient and inpatient care. Utilities were taken from the international bibliography. In a secondary analysis, indirect costs were included using a human capital approach. The model used a lifetime time horizon, and a discount rate of 5% was applied for health outcomes and costs. A one-way sensitivity analysis was conducted on key variables and patient sub-groups; uncertainty was evaluated using a Cost-Effectiveness Acceptability Curve.

Results

The average age of the cohort was 32 years, with diabetes duration of 19 years, an average HbA1c of 9.2%; 29% were men. A gain of 0.614 Quality Adjusted Life Years (QALYs) was estimated with the use of CSII therapy. The estimated ICER was MXN$478,020 per QALY in the base case, and MXN$369,593 when indirect costs were considered. The sensitivity analysis showed that, in adult patients with HbA1c > 9.0%, the ICER was MXN$262,237.

Conclusions

This is the first economic evaluation study that compares CSII therapy versus MDI therapy for T1D adult patients in Mexico. The insulin pump therapy can be considered cost-effective in the context of the IMSS when considering a threshold of three GDPs per capita with 43.9% probability. Results improve substantially when patients have an HbA1c above 9%.

Continuous subcutaneous insulin infusion vs modern multiple injection regimens in type 1 diabetes: an updated meta-analysis of randomized clinical trials

Meta-analyses of clinical trials comparing CSII with traditional insulin injections usually show a small, but significant advantage of CSII with respect to HbA1c and risk of severe hypoglycemia. On the other hand, CSII is associated with a small, but relevant risk of ketoacidosis, mainly due to malfunction of insulin pump and/or catheter occlusion. During last time, the technology of insulin pumps and infusion sets has improved as the profound evolution in type and schemes with traditional insulin injections. Aim of the present study is to update previous meta-analyses comparing CSII with traditional insulin injections in subjects with type 1 diabetes. Specific subgroup analyses were designed for assessing the effects of CSII in comparison with basal-bolus MDI, with short-acting analogues as bolus and long-acting analogues as basal insulin. In addition, an exploratory analysis was performed to verify the effect of CSII in insulin-naïve patients with type 1 diabetes. The present analysis includes all randomized clinical trials comparing CSII with traditional injections in type 1 diabetes, with a duration of at least 12 weeks. Animal studies were excluded, whereas no language or date restriction was imposed. If duplicate publications of a single trial were present, the paper containing more adequate information was considered as principal publication. In trials comparing CSII with basal-bolus MDI, performed before the introduction of rapid-acting analogues, regular human insulin was used for CSII, and as prandial insulin in control groups. CSII was associated with a significant reduction of A1c, in comparison with MDI, irrespective of the use of either human insulin or rapid-acting analogues. However, in trials with rapid-acting analogue the advantage of CSII was significantly smaller than in trials with regular human insulin (HbA1c difference: - 0.29[- 0.46; - 0.13] vs - 1.93[- 1.84; - 0.42]%; p = 0.02). Different rapid-acting analogues provided similar results (HbA1c reduction vs MDI: - 0.25 [- 0.48; - 0.02]%, p = 0.03, and - 0.29 [- 0.49; - 0.09]%, p = 0.005, for lispro and aspart, respectively). In addition, in trials comparing CSII with basal-bolus MDI, CSII reduced HbA1c to a similar extent irrespective of the use of either NPH or long-acting analogues as basal insulin in the control groups (HbA1c reduction vs MDI: - 0.31 [- 0.55; - 0.06]%, p = 0.01, and - 0.20 [- 0.38; - 0.03]%, p = 0.02, for NPH and long-acting analogues, respectively. With respect to severe hypoglycemia, CSII did not produce a significant reduction of risk in comparison with traditional insulin injections. Conversely, CSII was associated with a significant increase in the incidence of reported diabetic ketoacidosis (DKA). Notably, the increased risk of DKA was significant in trials comparing CSII with conventional insulin therapy, whereas only a nonsignificant trend toward an increased risk was observed in comparisons with basal-bolus MDI. Only two trials comparing CSII with basal-bolus MDI, both using rapid-acting analogues, were performed on insulin-naïve type 1 diabetic patients. When those two trials were analyzed separately, CSII did not produce any relevant effect on HbA1c (difference from control: - 0.10[- 0.38; + 0.17]%; p = 0.46). No meta-analysis could be performed on either severe hypoglycemia or DKA, which were not reported by one of the two trials. CSII seems to produce a small improvement in HbA1c in patients with type 1 diabetes inadequately controlled with MDI. This apparent effect, which could be partly due to publication bias, is smaller when MDI is properly performed using basal-bolus schemes with short-acting insulin analogues. Other outcomes different from HbA1c (such as quality of life) could be relevant for the choice of CSII instead of MDI. In addition, further studies are needed to better define the profile of patients who could benefit most from CSII.

A cost of illness study evaluating the burden of Wolfram syndrome in the United Kingdom

Background

Wolfram syndrome is a rare genetic, progressive, neurodegenerative disorder characterised by childhood-onset diabetes mellitus, diabetes insipidus, optic atrophy and deafness. To date, the economic burden of Wolfram syndrome has not been well-studied or reported. The aim of this study was to evaluate the cost of illness (COI) of all people with Wolfram syndrome in the UK and to identify major determinants of cost from a service provider perspective (National Health Service, NHS).

Methods

A prevalence-based approach was used to model the UK Wolfram syndrome specialist service. Model inputs were informed by a pragmatic literature review and UK reference costs, in conjunction with patient interviews and expert opinion. A deterministic sensitivity analysis (DSA) was run at 10% to identify major cost drivers.

Results

The total COI of all people with Wolfram syndrome to the NHS was £1,055,899 per year, with an average annual cost per person with Wolfram syndrome of £16,498. Costs associated with diabetes mellitus care, late-stage diabetes mellitus complications and hearing impairment contributed most to the COI (18.9, 21.4 and 15.8% of the COI, respectively). The DSA identified costs associated with hearing impairment, diabetes mellitus care and end-stage renal disease (a diabetes mellitus complication) as major model drivers.

Conclusions

The annual cost of Wolfram syndrome to the NHS was found to be substantial, with areas of potential cost savings identified, such as diabetes mellitus management. This model provides crucial information to facilitate economic evaluation of prospective therapies for this disease.

Drugs to Control Diabetes During Pregnancy

Diabetes is a common complication of pregnancy associated with both short- and long-term adverse maternal and offspring effects. All types of diabetes in pregnancy are increasing in prevalence. Treatment of diabetes in pregnancy, targeting glycemic control, improves both maternal and offspring outcomes, albeit imperfectly for many women. Pharmacologic treatment recommendations differ between pregestational and gestational diabetes. Improved treatment of diabetes in pregnancy will need to consider maternal disease heterogeneity and comorbidities as well as long-term offspring outcomes. In this review, the authors summarize recent clinical studies to highlight established pharmacologic treatments for diabetes in pregnancy and provide suggestions for further research.

Facilitating the transition of young people with long-term conditions through health services from childhood to adulthood: the Transition research programme

Background

As young people with long-term conditions move from childhood to adulthood, their health may deteriorate and their social participation may reduce. ‘Transition’ is the ‘process’ that addresses the medical, psychosocial and educational needs of young people during this time. ‘Transfer’ is the ‘event’ when medical care moves from children’s to adults’ services. In a typical NHS Trust serving a population of 270,000, approximately 100 young people with long-term conditions requiring secondary care reach the age of 16 years each year. As transition extends over about 7 years, the number in transition at any time is approximately 700.

Objectives

Purpose – to promote the health and well-being of young people with long-term conditions by generating evidence to enable NHS commissioners and providers to facilitate successful health-care transition. Objectives – (1) to work with young people to determine what is important in their transitional health care, (2) to identify the effective and efficient features of transitional health care and (3) to determine how transitional health care should be commissioned and provided.

Design, settings and participants

Three work packages addressed each objective. Objective 1. (i) A young people’s advisory group met monthly throughout the programme. (ii) It explored the usefulness of patient-held health information. (iii) A ‘Q-sort’ study examined how young people approached transitional health care. Objective 2. (i) We followed, for 3 years, 374 young people with type 1 diabetes mellitus (150 from five sites in England), autism spectrum disorder (118 from four sites in England) or cerebral palsy (106 from 18 sites in England and Northern Ireland). We assessed whether or not nine proposed beneficial features (PBFs) of transitional health care predicted better outcomes. (ii) We interviewed a subset of 13 young people about their transition. (iii) We undertook a discrete choice experiment and examined the efficiency of illustrative models of transition. Objective 3. (i) We interviewed staff and observed meetings in three trusts to identify the facilitators of and barriers to introducing developmentally appropriate health care (DAH). We developed a toolkit to assist the introduction of DAH. (ii) We undertook a literature review, interviews and site visits to identify the facilitators of and barriers to commissioning transitional health care. (iii) We synthesised learning on ‘what’ and ‘how’ to commission, drawing on meetings with commissioners.

Main outcome measures

Participation in life situations, mental well-being, satisfaction with services and condition-specific outcomes.

Strengths

This was a longitudinal study with a large sample; the conditions chosen were representative; non-participation and attrition appeared unlikely to introduce bias; the research on commissioning was novel; and a young person’s group was involved.

Limitations

There is uncertainty about whether or not the regions and trusts in the longitudinal study were representative; however, we recruited from 27 trusts widely spread over England and Northern Ireland, which varied greatly in the number and variety of the PBFs they offered. The quality of delivery of each PBF was not assessed. Owing to the nature of the data, only exploratory rather than strict economic modelling was undertaken.

Results and conclusions

(1) Commissioners and providers regarded transition as the responsibility of children’s services. This is inappropriate, given that transition extends to approximately the age of 24 years. Our findings indicate an important role for commissioners of adults’ services to commission transitional health care, in addition to commissioners of children’s services with whom responsibility for transitional health care currently lies. (2) DAH is a crucial aspect of transitional health care. Our findings indicate the importance of health services being commissioned to ensure that providers deliver DAH across all health-care services, and that this will be facilitated by commitment from senior provider and commissioner leaders. (3) Good practice led by enthusiasts rarely generalised to other specialties or to adults’ services. This indicates the importance of NHS Trusts adopting a trust-wide approach to implementation of transitional health care. (4) Adults’ and children’s services were often not joined up. This indicates the importance of adults’ clinicians, children’s clinicians and general practitioners planning transition procedures together. (5) Young people adopted one of four broad interaction styles during transition: ‘laid back’, ‘anxious’, ‘wanting autonomy’ or ‘socially oriented’. Identifying a young person’s style would help personalise communication with them. (6) Three PBFs of transitional health care were significantly associated with better outcomes: ‘parental involvement, suiting parent and young person’, ‘promotion of a young person’s confidence in managing their health’ and ‘meeting the adult team before transfer’. (7) Maximal service uptake would be achieved by services encouraging appropriate parental involvement with young people to make decisions about their care. A service involving ‘appropriate parental involvement’ and ‘promotion of confidence in managing one’s health’ may offer good value for money.

Future work

How might the programme’s findings be implemented by commissioners and health-care providers? What are the most effective ways for primary health care to assist transition and support young people after transfer?

Study registration

This study is registered as UKCRN 12201, UKCRN 12980, UKCRN 12731 and UKCRN 15160.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Continuous subcutaneous insulin infusion versus multiple daily injections in children and young people at diagnosis of type 1 diabetes: the SCIPI RCT

BACKGROUND

The risk of developing long-term complications of type 1 diabetes (T1D) is related to glycaemic control and is reduced by the use of intensive insulin treatment regimens: multiple daily injections (MDI) (≥ 4) and continuous subcutaneous insulin infusion (CSII). Despite a lack of evidence that the more expensive treatment with CSII is superior to MDI, both treatments are used widely within the NHS.

OBJECTIVES

(1) To compare glycaemic control during treatment with CSII and MDI and (2) to determine safety and cost-effectiveness of the treatment, and quality of life (QoL) of the patients.

DESIGN

A pragmatic, open-label randomised controlled trial with an internal pilot and 12-month follow-up with 1 : 1 web-based block randomisation stratified by age and centre.

SETTING

Fifteen diabetes clinics in hospitals in England and Wales.

PARTICIPANTS

Patients aged 7 months to 15 years.

INTERVENTIONS

Continuous subsutaneous insulin infusion or MDI initiated within 14 days of diagnosis of T1D.

DATA SOURCES

Data were collected at baseline and at 3, 6, 9 and 12 months using paper forms and were entered centrally. Data from glucometers and CSII were downloaded. The Health Utilities Index Mark 2 was completed at each visit and the Pediatric Quality of Life Inventory (PedsQL, diabetes module) was completed at 6 and 12 months. Costs were estimated from hospital patient administration system data.

OUTCOMES

The primary outcome was glycosylated haemoglobin (HbA_1c) concentration at 12 months. The secondary outcomes were (1) HbA_1c concentrations of < 48 mmol/mol, (2) severe hypoglycaemia, (3) diabetic ketoacidosis (DKA), (4) T1D- or treatment-related adverse events (AEs), (5) change in body mass index and height standard deviation score, (6) insulin requirements, (7) QoL and (8) partial remission rate. The economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS

A total of 293 participants, with a median age of 9.8 years (minimum 0.7 years, maximum 16 years), were randomised (CSII, n = 149; MDI, n = 144) between May 2011 and January 2015. Primary outcome data were available for 97% of participants (CSII, n = 143; MDI, n = 142). At 12 months, age-adjusted least mean squares HbA_1c concentrations were comparable between groups: CSII, 60.9 mmol/mol [95% confidence interval (CI) 58.5 to 63.3 mmol/mol]; MDI, 58.5 mmol/mol (95% CI 56.1 to 60.9 mmol/mol); and the difference of CSII - MDI, 2.4 mmol/mol (95% CI -0.4 to 5.3 mmol/mol). For HbA_1c concentrations of < 48 mmol/mol (CSII, 22/143 participants; MDI, 29/142 participants), the relative risk was 0.75 (95% CI 0.46 to 1.25), and for partial remission rates (CSII, 21/86 participants; MDI, 21/64), the relative risk was 0.74 (95% CI 0.45 to 1.24). The incidences of severe hypoglycaemia (CSII, 6/144; MDI, 2/149 participants) and DKA (CSII, 2/144 participants; MDI, 0/149 participants) were low. In total, 68 AEs (14 serious) were reported during CSII treatment and 25 AEs (eight serious) were reported during MDI treatment. Growth outcomes did not differ. The reported insulin use was higher with CSII (mean difference 0.1 unit/kg/day, 95% CI 0.0 to 0.2 unit/kg/day; p = 0.01). QoL was slightly higher for those randomised to CSII. From a NHS perspective, CSII was more expensive than MDI mean total cost (£1863, 95% CI £1620 to £2137) with no additional QALY gains (-0.006 QALYs, 95% CI -0.031 to 0.018 QALYs).

LIMITATIONS

Generalisability beyond 12 months is uncertain.

CONCLUSIONS

No clinical benefit of CSII over MDI was identified. CSII is not a cost-effective treatment in patients representative of the study population.

FUTURE WORK

Longer-term follow-up is required to determine if clinical outcomes diverge after 1 year. A qualitative exploration of patient and professional experiences of MDI and CSII should be considered.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29255275 and EudraCT 2010-023792-25.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 42. See the NIHR Journals Library website for further project information. The cost of insulin pumps and consumables supplied by F. Hoffman-La Roche AG (Basel, Switzerland) for the purpose of the study were subject to a 25% discount on standard NHS costs.

Continuous subcutaneous insulin infusion versus multiple daily injection regimens in children and young people at diagnosis of type 1 diabetes: pragmatic randomised controlled trial and economic evaluation

OBJECTIVE

To compare the efficacy, safety, and cost utility of continuous subcutaneous insulin infusion (CSII) with multiple daily injection (MDI) regimens during the first year following diagnosis of type 1 diabetes in children and young people.

DESIGN

Pragmatic, multicentre, open label, parallel group, randomised controlled trial and economic evaluation.

SETTING

15 paediatric National Health Service (NHS) diabetes services in England and Wales. The study opened to recruitment in May 2011 and closed in January 2017.

PARTICIPANTS

Patients aged between 7 months and 15 years, with a new diagnosis of type 1 diabetes were eligible to participate. Patients who had a sibling with the disease, and those who took drug treatments or had additional diagnoses that could have affected glycaemic control were ineligible.

INTERVENTIONS

Participants were randomised, stratified by age and treating centre, to start treatment with CSII or MDI within 14 days of diagnosis. Starting doses of aspart (CSII and MDI) and glargine or detemir (MDI) were calculated according to weight and age, and titrated according to blood glucose measurements and according to local clinical practice.

MAIN OUTCOME MEASURES

Primary outcome was glycaemic control (as measured by glycated haemoglobin; HbA1c) at 12 months. Secondary outcomes were percentage of patients in each treatment arm with HbA1c within the national target range, incidence of severe hypoglycaemia and diabetic ketoacidosis, change in height and body mass index (as measured by standard deviation scores), insulin requirements (units/kg/day), partial remission rate (insulin dose adjusted HbA1c <9), paediatric quality of life inventory score, and cost utility based on the incremental cost per quality adjusted life year (QALY) gained from an NHS costing perspective.

RESULTS

294 participants were randomised and 293 included in intention to treat analyses (CSI, n=144; MDI, n=149). At 12 months, mean HbA1c was comparable with clinically unimportant differences between CSII and MDI participants (60.9 mmol/mol v 58.5 mmol/mol, mean difference 2.4 mmol/mol (95% confidence interval -0.4 to 5.3), P=0.09). Achievement of HbA1c lower than 58 mmol/mol was low among the two groups (66/143 (46%) CSII participants v 78/142 (55%) MDI participants; relative risk 0.84 (95% confidence interval 0.67 to 1.06)). Incidence of severe hypoglycaemia and diabetic ketoacidosis were low in both groups. Fifty four non-serious and 14 serious adverse events were reported during CSII treatment, and 17 non-serious and eight serious adverse events during MDI treatment. Parents (but not children) reported superior PedsQL scores for those patients treated with CSII compared to those treated with MDI. CSII was more expensive than MDI by £1863 (€2179; $2474; 95% confidence interval £1620 to £2137) per patient, with no additional QALY gains (difference -0.006 (95% confidence interval -0.031 to 0.018)).

CONCLUSION

During the first year following type 1 diabetes diagnosis, no clinical benefit of CSII over MDI was identified in children and young people in the UK setting, and treatment with either regimen was suboptimal in achieving HbA1c thresholds. CSII was not cost effective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29255275; European Clinical Trials Database 2010-023792-25.

The influence of demographic, social-educational determinants and diabetes management on agreement between glucometer and logbook and its impact on glycemic control in patients with type 1 diabetes: a follow-up study

BACKGROUND

The primary objective of this study was to evaluate the demographic, clinical, social-educational determinants and diabetes management factors that have influenced the agreement between glycaemia obtained from a glucometer and logbook; the second objective was to evaluate the influence of the above-mentioned factors on glycemic control and its trajectories in Type 1 diabetes (T1D) over 1 year follow-up period during routine clinical practice.

METHODS

This was a prospective observational cohort study conducted at the Diabetes Unit at Rio de Janeiro's State University, between May 2017 and May 2018. All consecutive patients with clinical diagnosis of T1D that attended the Diabetes Unit between April and June 2017 were enrolled in this study.

RESULTS

Data were obtained from 158 patients. Overall, for 112 (73.2%) of the patients, we found no agreement between glycaemia obtained from a glucometer and the logbook (group 2). In 41 (26.8%) of the patients there was an agreement (group 1). Patients from group 1 presented a lower mean glycated hemoglobin (HbA1c) (p = 0.03) and a tendency to have a lower baseline HbA1c (p = 0.08), they received more frequently strips for glucose monitoring from the Sistema Único de Saúde (SUS) (p = 0.047) and were more adherent to the prescribed diet (p = 0.01) than patients from group 2. Multivariate analysis of this agreement (as a dependent variable) showed that adherence to diet was the only significant independent variable. Significant difference was noted between baseline and final HbA1c [(9.4 ± 2.2%) vs (9.03 ± 1.8%), p = 0.017], respectively.

CONCLUSIONS

Our study revealed that the majority of T1D patients that were followed at a tertiary center did not have significant agreement between glycaemia obtained from a glucometer and a logbook. Adherence to diet was the main factor related to the agreement, but the supply of strips by SUS should also be considered in clinical practice.

Utility of Real-Time and Retrospective Continuous Glucose Monitoring in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials

In the present study, we aimed to investigate the effects of continuous glucose monitoring (CGM) on blood glucose levels, body weight, blood pressure, and hypoglycaemia in patients with type 2 diabetes mellitus using a meta-analysis of randomized controlled trials (RCTs). A literature search was performed using MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. RCTs using CGM in patients with type 2 diabetes mellitus were then selected. Statistical analysis included calculation of the standardized mean difference (SMD) or risk ratio and 95% confidence intervals (CIs) using a random effects model. After literature search, seven RCTs (669 patients) satisfied the eligibility criteria established herein and were included into the meta-analysis. Compared with the self-monitoring blood glucose group, the CGM group exhibited significantly lower HbA1c levels (SMD, -0.35; 95% CI, -0.59--0.10; P = 0.006) and shorter time spent with hypoglycaemia (SMD, -0.42; 95% CI, -0.70--0.13; P = 0.004). Conversely, no differences in body weight and blood pressure were observed between the groups. CGM in patients with type 2 diabetes mellitus could reduce HbA1c levels and time spent with hypoglycaemia. However, because few RCTs were included in this present study and heterogeneity was also noted, care should be taken when interpreting the results.

Insulin Bolus Administration in Insulin Pump Therapy: Effect of Bolus Delivery Speed on Insulin Absorption from Subcutaneous Tissue

BACKGROUND

This study assessed subcutaneous absorption kinetics of rapid-acting insulin administered as a bolus using bolus delivery speeds commonly employed in commercially available insulin pumps (i.e., 2 and 40 s for delivering 1 insulin unit).

MATERIALS AND METHODS

Twenty C-peptide-negative type 1 diabetic subjects were studied on two occasions, separated by at least 7 days, using the euglycemic clamp procedure. After an overnight fast, subjects were given, in random order, a subcutaneous insulin bolus (15 U of insulin lispro, Eli Lilly) either for 30 s using an Animas IR2020 pump (fast bolus delivery) or for 10 min using a Medtronic Minimed Paradigm 512 pump (slow bolus delivery).

RESULTS

Fast bolus delivery resulted in an earlier onset of insulin action as compared with slow bolus delivery (21.0 ± 2.5 vs. 34.3 ± 2.7 min; P < 0.002). Furthermore, time to reach maximum insulin effect was found to be 27 min earlier with fast bolus delivery as compared with slow bolus delivery (98 ± 11 vs. 125 ± 16 min; P < 0.005). In addition, the area under the plasma insulin curve from 0 to 60 min for fast bolus delivery was greater than the one for slow bolus delivery (10,307 ± 1291 vs. 8192 ± 865 min·pmol/L; P = 0.027).

CONCLUSIONS

Results suggest that insulin bolus delivery with fast delivery speed may result in more rapid insulin absorption and, thus, may provide a better control of meal-related glucose excursions than that obtained with bolus delivery using slow delivery speeds. Our findings may have important implications for the future design of the bolus delivery unit of insulin pumps.

Stressful Life Events in Young Adults With Type 1 Diabetes in the U.S. T1D Exchange Clinic Registry

PURPOSE

The purpose was to test associations among stressful life events, frequency of missed insulin doses, and glycemic control in young adults with type 1 diabetes (T1D).

DESIGN

The study was a cross-sectional descriptive secondary analysis.

METHODS

Data from 2,921 participants (ages 18-26 years) in the U.S. T1D Exchange Clinic Registry were analyzed. Report of a stressful life event was defined as one or more positive responses on a 17-item stressful life events index and defined as a dichotomous variable (yes or no). Frequency of missed insulin doses was measured using a single self-report item and collapsed into two levels (fewer than three times a week, three or more times a week). The glycosylated hemoglobin (A1c) level recorded at the time of enrollment was used to assess glycemic control.

FINDINGS

Nearly half (48.6%) of the participants reported having a stressful life event during the previous year. The most frequently reported stressful life events were problems at work or school (16.1%), serious arguments with family members or a close friend (15.2%), and financial problems in the family (13.8%). Compared to the participants not reporting stressful life events, those who reported stressful life events were more likely to be older, female, with a higher educational attainment level, and not working or unemployed. Those who reported a stressful life event were more likely than those who did not to say they typically missed insulin doses at least three times a week and less likely to say they typically missed insulin doses fewer than three times a week (p < .001 adjusted for age, sex, race or ethnicity, educational attainment level, duration of T1D diagnosis, and insulin delivery method). Mean A1c level was higher for the group who reported having a stressful life event in the past 12 months compared to the group who did not (8.7 ± 1.8% vs. 8.2 ± 1.6%; adjusted p < .001). The results of a mediation analysis suggest that the measure of frequency of missed insulin doses may be a mediator of the relationship between recent stressful life events and glycemic control (Sobel test: ab = .841, 95% confidence interval = 0.064-1.618).

CONCLUSIONS

These findings suggest that, for young adults with T1D, the experience of stressful life events may increase their risk for poorer glycemic control, possibly by disrupting adherence with insulin doses.

CLINICAL RELEVANCE

Further exploration of these relationships may allow for the potential for identifying those at risk and assisting them with more positive approaches to managing stressful events.

Risk and Relevance of Insulin Pump Therapy in the Aetiology of Ketoacidosis in People with Type 1 Diabetes

OBJECTIVE

The aim of this systematic data analysis was to determine the prevalence of diabetic ketoacidosis (DKA) as well as hypoglycemic and hyperglycemic disorders during insulin pump therapy (CSII) in patients with type 1 diabetes. The main focus was to investigate whether CSII patients have more DKA than the general type 1 diabetes population.

SUBJECTS AND METHODS

This retrospective study with patients who were treated in our treatment center from 2003 to 2016 includes data from 229 patients (52.4% male, 47.6% female, 37.2±16.3 years; DKA: 93, hypoglycemia: 66, hyperglycemia: 70).

RESULTS

Intensified insulin therapy was the most common treatment regimen in the study cohort (73.4%), followed by CSII (24%). However, 32.3% of the patients with DKA were on CSII. This number of DKA cases among the insulin pump users in our study cohort was higher than the prevalence reported in a previously published study by Reichel et al. (2013; p<0.05) and in a customer database (p<0.005). Most common causes of DKA in our study cohort were patient errors (43.3%) or insulin resistance induced by an underlying infection (29.8%). Device malfunction caused 13.5% of all DKA cases with an overwhelming majority on insulin pump treatment (93%). Overall, patient errors caused more DKA cases than device malfunctions.

CONCLUSIONS

Our findings suggest that despite development of more sophisticated insulin pump devices, DKA is still more frequent with CSII than with other kinds of insulin treatment.

The clinician factor: Personality characteristics of clinicians and their impact upon clinical outcomes in the management of children and adolescents with type 1 diabetes

OBJECTIVE

The purpose of this study was to estimate clinician qualities that influence metabolic outcomes in youth with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Data were gathered over two 3 month periods in a large tertiary diabetes center (1500 patients, 8 clinicians) from patients with type 1 diabetes who received continuous care from each clinician. Data included sex, age, diabetes duration, insulin regimen, body mass index (BMI), insulin dose and episodes of severe hypoglycemia. Clinician data included target blood glucose levels, target glycated hemoglobin (HbA1c), Diabetes Attitude Scale and Big 5 Personality Inventory Scale. Mean HbA1c per clinician was the primary outcome variable.

RESULTS

The 8 clinicians saw a total of 464 patients during the first time period, and 603 in the second time period. Lowest to highest mean HbA1c per clinician varied by 0.7%. There were small but statistically significant differences between clinicians with their patients' age at diagnosis, duration of diabetes, age, gender, treatment type and BMI SD score. After controlling for these differences, the clinician characteristics that were associated with lower mean HbA1c were having no lower limit in target HbA1c and being self-reportedly "less agreeable." The impact of these clinician attitudinal traits was equivalent to the combined effects of patient characteristics and treatment type.

CONCLUSIONS

There was a significant variation in metabolic outcomes between treating clinicians. After controlling for patient clinical differences, clinician mean HbA1c was associated with lower limit in target HbA1c and being "less agreeable." Clinicians who were more demanding and dogmatic appeared to have better outcomes.

Glycemic Control in Adult Type 1 Diabetes Patients with Insulin Glargine, Insulin Detemir, or Continuous Subcutaneous Insulin Infusion in Daily Practice

BACKGROUNDS

This study aims to compare glycemic control of persons with type 1 diabetes using multiple daily injections (MDI) with insulin glargine versus insulin detemir or with continuous subcutaneous insulin infusion (CSII) in daily practice.

SUBJECTS AND METHODS

All adult individuals with type 1 diabetes (n = 1053) were identified from the electronic patient database in North Karelia, Finland. The persons' individual data for insulin treatment, diabetic ketoacidosis (DKA), and hemoglobin A_1c (HbA1c) measurements during the year 2014 were obtained from medical records. Persons using long-acting insulin analogs or CSII were included in the analyses (n = 1004).

RESULTS

Altogether, 47.7% used glargine, 43.9% used detemir, and 8.4% used CSII. The mean HbA1c was lower in the CSII group (63 mmol/mol [7.9%]) compared with the glargine group (66 mmol/mol [8.2%]) or the detemir group (67 mmol/mol [8.3%]). The overall rate of DKA was 5.1% per year. The rate of DKA was higher in the detemir group compared with the glargine group (6.3% per year vs. 3.8% per year, respectively, P < 0.049). In logistic regression analyses, the higher rate of DKA with detemir use was explained by HbA1c.

CONCLUSIONS

In daily practice, the glycemic control of type 1 diabetes patients with MDI was similar regardless of basal insulin, glargine, or detemir, whereas CSII allowed better glycemic control than MDI. The rate of DKA was higher with detemir than with glargine, but this is likely related to higher HbA1c rather than insulin regimen.

Cost-effectiveness of insulin pumps compared with multiple daily injections both provided with structured education for adults with type 1 diabetes: a health economic analysis of the Relative Effectiveness of Pumps over Structured Education (REPOSE) randomised controlled trial

OBJECTIVES

To assess the long-term cost-effectiveness of insulin pumps and Dose Adjustment for Normal Eating (pumps+DAFNE) compared with multiple daily insulin injections and DAFNE (MDI+DAFNE) for adults with type 1 diabetes mellitus (T1DM) in the UK.

METHODS

We undertook a cost-utility analysis using the Sheffield Type 1 Diabetes Policy Model and data from the Relative Effectiveness of Pumps over Structured Education (REPOSE) trial to estimate the lifetime incidence of diabetic complications, intervention-based resource use and associated effects on costs and quality-adjusted life years (QALYs). All economic analyses took a National Health Service and personal social services perspective and discounted costs and QALYs at 3.5% per annum. A probabilistic sensitivity analysis was performed on the base case. Further uncertainties in the cost of pumps and the evidence used to inform the model were explored using scenario analyses.

SETTING

Eight diabetes centres in England and Scotland.

PARTICIPANTS

Adults with T1DM who were eligible to receive a structured education course and did not have a strong clinical indication or a preference for a pump.

INTERVENTION

Pumps+DAFNE.

COMPARATOR

MDI+DAFNE.

MAIN OUTCOME MEASURES

Incremental costs, incremental QALYs gained and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared with MDI+DAFNE, pumps+DAFNE was associated with an incremental discounted lifetime cost of +£18 853 (95% CI £6175 to £31 645) and a gain in discounted lifetime QALYs of +0.13 (95% CI -0.70 to +0.96). The base case mean ICER was £142 195 per QALY gained. The probability of pump+DAFNE being cost-effective using a cost-effectiveness threshold of £20 000 per QALY gained was 14.0%. All scenario and subgroup analyses examined indicated that the ICER was unlikely to fall below £30 000 per QALY gained.

CONCLUSIONS

Our analysis of the REPOSE data suggests that routine use of pumps in adults without an immediate clinical need for a pump, as identified by National Institute for Health and Care Excellence, would not be cost-effective.

TRIAL REGISTRATION NUMBER

ISRCTN61215213.

A longitudinal study of fear of hypoglycaemia in adults with type 1 diabetes

AIMS

To investigate fear of hypoglycaemia (FoH) longitudinally in a cross-sectional study of adult patients with type 1 diabetes. Specifically, we investigated two subgroups of patients who over 4 years either showed a substantial increase or decrease in level of FoH to identify factors associated with changes in FoH.

METHODS

The Swedish version of the Hypoglycaemia Fear Survey (HFS) along with a questionnaire to assess hypoglycaemia history was sent by mail to 764 patients in 2010. The responders in 2010 (n = 469) received another set of the same two questionnaires in 2014. HbA1c, insulin regimen, weight and creatinine from 2010 and 2014 were obtained from medical records. Those with an absolute difference in HFS scores ≥ 75th percentile were included in the subgroup analyses. Statistical analyses included one-sample t tests, chi-square and McNemar's test.

RESULTS

The absolute difference in the HFS total score (n = 347) between 2010 and 2014 was m = ±7.6, SD ± 6. In the increased FoH group, more patients reported a high level of moderate hypoglycaemic episodes as well as impaired awareness of hypoglycaemia in 2014 compared with the decreased FoH group. There were more subjects in the increased FoH group with insulin pumps in 2014 and in 2010. In the decreased FoH group, more patients had a high frequency of daily self-monitoring of blood glucose (SMBG) in 2010 and in 2014.

CONCLUSIONS

Fear of hypoglycaemia is stable across time for most patients. Changes in fear level are associated with changes in hypoglycaemia frequency. Thus, asking patients about changes in hypoglycaemia experiences is of great importance.

A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial

BACKGROUND

Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy.

DESIGN

Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI.

SETTING

Eight secondary care diabetes centres in the UK.

PARTICIPANTS

Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps.

INTERVENTIONS

Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm^® Veo^TM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK).

MAIN OUTCOME MEASURES

Primary outcome - change in glycated haemoglobin (HbA_1c) at 2 years in participants whose baseline HbA_1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA_1c ≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months - moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness.

RESULTS

We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA_1c of ≥ 7.5%. HbA_1c and severe hypoglycaemia improved in both groups. The drop in HbA_1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA_1c change at 2 years, at which the baseline HbA_1c was ≥ 7.5%, was -0.24% [95% confidence interval (CI) -0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of -0.36% (95% CI -0.64% to -0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews.

LIMITATION

Blinding of pump therapy was not possible, although an objective primary outcome was used.

CONCLUSION

Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM.

RESEARCH PRIORITY

To understand why few patients achieve a HbA_1c of < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61215213.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 20. See the NIHR Journals Library website for further project information.

Glucose-responsive insulin delivery for type 1 diabetes: The artificial pancreas story

Insulin replacement therapy is integral to the management of type 1 diabetes, which is characterised by absolute insulin deficiency. Optimal glycaemic control, as assessed by glycated haemoglobin, and avoidance of hyper- and hypoglycaemic excursions have been shown to prevent diabetes-related complications. Insulin pump use has increased considerably over the past decade with beneficial effects on glycaemic control, quality of life and treatment satisfaction. The advent and progress of ambulatory glucose sensor technology has enabled continuous glucose monitoring based on real-time glucose levels to be integrated with insulin therapy. Low glucose and predictive low glucose suspend systems are currently used in clinical practice to mitigate against hypoglycaemia, and provide the first step towards feedback glucose control. The more advanced technology approach, an artificial pancreas or a closed-loop system, gradually increases and decreases insulin delivery in a glucose-responsive fashion to mitigate against hyper- and hypoglycaemia. Randomised outpatient clinical trials over the past 5 years have demonstrated the feasibility, safety and efficacy of the approach, and the recent FDA approval of the first single hormone closed-loop system establishes a new standard of care for people with type 1 diabetes.

Insulin delivery and nocturnal glucose control in children and adolescents with type 1 diabetes

Introduction: Nocturnal glucose control remains challenging in children and adolescents with type 1 diabetes due to highly variable overnight insulin requirements. The issue may be addressed by glucose responsive insulin delivery based on real-time continuous glucose measurements.

Areas covered: This review outlines recent developments of glucose responsive insulin delivery systems from a paediatric perspective. We cover threshold-based suspend application, predictive low glucose suspend, and more advanced single hormone and dual-hormone closed-loop systems. Approaches are evaluated in relation to nocturnal glucose control particularly during outpatient randomised controlled trials.

Expert opinion: Significant progress translating research from controlled clinical centre settings to free-living unsupervised home studies have been achieved over the past decade. Nocturnal glycaemic control can be improved whilst reducing the risk of hypoglycaemia with closed-loop systems. Following the US regulatory approval of the first hybrid closed-loop system in non-paediatric population, large multinational closed-loop clinical trials and pivotal studies including paediatric populations are underway or in preparation to facilitate the use of closed-loop systems in clinical practice.

Pregnancy Outcomes and Insulin Requirements in Women with Type 1 Diabetes Treated with Continuous Subcutaneous Insulin Infusion and Multiple Daily Injections: Cohort Study

BACKGROUND

We aimed to compare glycemic control, insulin requirements, and outcomes in women with type 1 diabetes in pregnancy treated with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI).

METHODS

A retrospective cohort study was conducted of singleton pregnancies (>20 weeks gestation) in women with type 1 diabetes (2010-2015) at a specialist multidisciplinary maternity network in Australia. Antenatal characteristics, diabetes history and treatment details, and maternal and neonatal outcomes were compared for women with type 1 diabetes using CSII and MDI. Bolus calculator settings were reviewed for CSII. Data were obtained from individual medical records, linkage to pathology, and the Birthing Outcomes System database.

RESULTS

There were no differences in maternal characteristics or diabetes history between women managed with CSII (n = 40) and MDI (n = 127). Women treated with CSII required less insulin and less increase in total daily insulin dose/kg than MDI (40% vs. 52%). Both groups achieved similar glycemic control and no differences in pregnancy outcome. In the CSII group, carbohydrate:insulin ratios were intensified across gestation (30% breakfast, 27% lunch, 22% dinner), and insulin sensitivity factors (ISFs) changed little (7% breakfast, 0% lunch, -10% dinner).

CONCLUSIONS

There was no difference in glycemic control or pregnancy outcomes in women using CSII or MDI managed in a multidisciplinary setting. Greater adjustments are needed to ISFs with CSII therapy. Overall, these data do not support recommending CSII in pregnancy with potentially higher patient and staff demands and costs and lack of improvement in HbA1c and pregnancy outcomes.

Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE)

Objective To compare the effectiveness of insulin pumps with multiple daily injections for adults with type 1 diabetes, with both groups receiving equivalent training in flexible insulin treatment.Design Pragmatic, multicentre, open label, parallel group, cluster randomised controlled trial (Relative Effectiveness of Pumps Over MDI and Structured Education (REPOSE) trial).Setting Eight secondary care centres in England and Scotland.Participants Adults with type 1 diabetes who were willing to undertake intensive insulin treatment, with no preference for pumps or multiple daily injections. Participants were allocated a place on established group training courses that taught flexible intensive insulin treatment ("dose adjustment for normal eating," DAFNE). The course groups (the clusters) were then randomly allocated in pairs to either pump or multiple daily injections.Interventions Participants attended training in flexible insulin treatment (using insulin analogues) structured around the use of pump or injections, followed for two years.Main outcome measures The primary outcomes were a change in glycated haemoglobin (HbA1c) values (%) at two years in participants with baseline HbA1c value of ≥7.5% (58 mmol/mol), and the proportion of participants achieving an HbA1c value of <7.5%. Secondary outcomes included body weight, insulin dose, and episodes of moderate and severe hypoglycaemia. Ancillary outcomes included quality of life and treatment satisfaction.Results 317 participants (46 courses) were randomised (156 pump and 161 injections). 267 attended courses and 260 were included in the intention to treat analysis, of which 235 (119 pump and 116 injection) had baseline HbA1c values of ≥7.5%. Glycaemic control and rates of severe hypoglycaemia improved in both groups. The mean change in HbA1c at two years was -0.85% with pump treatment and -0.42% with multiple daily injections. Adjusting for course, centre, age, sex, and accounting for missing values, the difference was -0.24% (-2.7 mmol/mol) in favour of pump users (95% confidence interval -0.53 to 0.05, P=0.10). Most psychosocial measures showed no difference, but pump users showed greater improvement in treatment satisfaction and some quality of life domains (dietary freedom and daily hassle) at 12 and 24 months.Conclusions Both groups showed clinically relevant and long lasting decreases in HbA1c, rates of severe hypoglycaemia, and improved psychological measures, although few participants achieved glucose levels currently recommended by national and international guidelines. Adding pump treatment to structured training in flexible intensive insulin treatment did not substantially enhance educational benefits on glycaemic control, hypoglycaemia, or psychosocial outcomes in adults with type 1 diabetes. These results do not support a policy of providing insulin pumps to adults with poor glycaemic control until the effects of training on participants' level of engagement in intensive self management have been determined.Trial registration Current Controlled Trials ISRCTN61215213.

Effect of Chinese herbal medicine on stroke patients with type 2 diabetes

ETHNOPHARMACOLOGICAL RELEVANCE

Complications of type 2 diabetes (T2D) include stroke, which is a cerebrovascular disturbance characterized by reduced blood flow in the brain, leading to death or physical disability. Chinese herbal medicine (CHM) has been widely used in ancient China for the treatment of diabetes and stroke by supplementing Qi and activating blood circulation.

AIM OF THE STUDY

This study aimed to investigate the frequencies and patterns of CHM treatment for stroke patients with T2D and the outcomes of long-term use in Taiwan.

MATERIALS AND METHODS

We identified 3079 stroke patients (ICD-9-CM: 430-438) with T2D. We allocated 618 stroke patients, matched for age, gender, and T2D-to-stroke duration, to both CHM and non-CHM groups. Chi-square test, conditional multivariable logistic regression, Kaplan-Meier method, and the log-rank test were used in this study.

RESULTS

The CHM group was characterized by more cases of chronic obstructive pulmonary disease, ulcer disease, hyperlipidemia, tobacco use, and higher income. The cumulative survival probability was higher in the CHM group (P<0.001, log rank test); after adjusting for comorbidities, income, and urbanization level, this group also exhibited a lower mortality hazard ratio (0.37, 95% confidence interval [0.25-0.55]). Shu-Jing-Huo-Xue-Tang, Xue-Fu-Zhu-Yu-Tang, and Du-Huo-Ji-Sheng-Tang; and Dan-Shen, Niu-Xi, and Yan-Hu-Suo represented the top three formulas and herbs, respectively.

CONCLUSION

The use of CHM as adjunctive therapy may improve the overall survival (OS) of stroke patients with T2D. The list of the comprehensive herbal medicines that they used might be useful in future large-scale, randomized clinical investigations of agent effectiveness, safety, and potential interactions with conventional treatments in stroke patients with T2D.

Integrated sensor-augmented pump therapy systems [the MiniMed® Paradigm™ Veo system and the Vibe™ and G4® PLATINUM CGM (continuous glucose monitoring) system] for managing blood glucose levels in type 1 diabetes: a systematic review and economic evaluation

BACKGROUND

In recent years, meters for continuous monitoring of interstitial fluid glucose have been introduced to help people with type 1 diabetes mellitus (T1DM) to achieve better control of their disease.

OBJECTIVE

The objective of this project was to summarise the evidence on the clinical effectiveness and cost-effectiveness of the MiniMed(®) Paradigm™ Veo system (Medtronic Inc., Northridge, CA, USA) and the Vibe™ (Animas(®) Corporation, West Chester, PA, USA) and G4(®) PLATINUM CGM (continuous glucose monitoring) system (Dexcom Inc., San Diego, CA, USA) in comparison with multiple daily insulin injections (MDIs) or continuous subcutaneous insulin infusion (CSII), both with either self-monitoring of blood glucose (SMBG) or CGM, for the management of T1DM in adults and children.

DATA SOURCES

A systematic review was conducted in accordance with the principles of the Centre for Reviews and Dissemination guidance and the National Institute for Health and Care Excellence Diagnostic Assessment Programme manual. We searched 14 databases, three trial registries and two conference proceedings from study inception up to September 2014. In addition, reference lists of relevant systematic reviews were checked. In the absence of randomised controlled trials directly comparing Veo or an integrated CSII + CGM system, such as Vibe, with comparator interventions, indirect treatment comparisons were performed if possible.

METHODS

A commercially available cost-effectiveness model, the IMS Centre for Outcomes Research and Effectiveness diabetes model version 8.5 (IMS Health, Danbury, CT, USA), was used for this assessment. This model is an internet-based, interactive simulation model that predicts the long-term health outcomes and costs associated with the management of T1DM and type 2 diabetes. The model consists of 15 submodels designed to simulate diabetes-related complications, non-specific mortality and costs over time. As the model simulates individual patients over time, it updates risk factors and complications to account for disease progression.

RESULTS

Fifty-four publications resulting from 19 studies were included in the review. Overall, the evidence suggests that the Veo system reduces hypoglycaemic events more than other treatments, without any differences in other outcomes, including glycated haemoglobin (HbA1c) levels. We also found significant results in favour of the integrated CSII + CGM system over MDIs with SMBG with regard to HbA1c levels and quality of life. However, the evidence base was poor. The quality of the included studies was generally low, often with only one study comparing treatments in a specific population at a specific follow-up time. In particular, there was only one study comparing Veo with an integrated CSII + CGM system and only one study comparing Veo with a CSII + SMBG system in a mixed population. Cost-effectiveness analyses indicated that MDI + SMBG is the option most likely to be cost-effective, given the current threshold of £30,000 per quality-adjusted life-year gained, whereas integrated CSII + CGM systems and Veo are dominated and extendedly dominated, respectively, by stand-alone, non-integrated CSII with CGM. Scenario analyses did not alter these conclusions. No cost-effectiveness modelling was conducted for children or pregnant women.

CONCLUSIONS

The Veo system does appear to be better than the other systems considered at reducing hypoglycaemic events. However, in adults, it is unlikely to be cost-effective. Integrated systems are also generally unlikely to be cost-effective given that stand-alone systems are cheaper and, possibly, no less effective. However, evidence in this regard is generally lacking, in particular for children. Future trials in specific child, adolescent and adult populations should include longer term follow-up and ratings on the European Quality of Life-5 Dimensions scale at various time points with a view to informing improved cost-effectiveness modelling.

STUDY REGISTRATION

PROSPERO Registration Number CRD42014013764.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Do We Need Updated Guidelines on the Use of Insulin Pump Therapy in Type 2 Diabetes? A Review of National and International Practice Guidelines

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) is used less for type 2 than for type 1 diabetes because of inconsistencies in evidence of effectiveness. We reviewed published guidelines on intensive insulin therapy in type 2 diabetes to assess whether updating of guidance is needed with respect to evidence used and recommendations for CSII in diabetes management.

METHODS

A literature review was performed to identify published national and international guidelines on type 2 diabetes management. Searches were performed using PubMed, Cochrane Library, and Embase databases, and websites of national health care agencies, reimbursement agencies, and professional associations. Searches were limited to articles published in English between 2004 and 2014 and 1666 unique hits were identified, of which 22 were reviewed following screening.

RESULTS

Only 6 of the 22 guidelines identified from North and South America, Western Europe, Greece, and Israel provided specific recommendations on intensive insulin therapy and the role of CSII, and only 1 provided information on the grade of evidence supporting recommendations. Quality appraisal based on the AGREE II tool suggested that published guidelines may have limitations in terms of search methodology and evidence grading, and findings were of mixed rigor and clarity. Only 3 guidelines described the population for whom CSII may be appropriate.

CONCLUSIONS

Guidelines need to improve the evidence base, rigor, clarity, and grading of evidence associated with recommendations on intensive insulin therapy in type 2 diabetes. Future updates may benefit from considering recent evidence on the efficacy of CSII in poorly controlled patients on MDI.

A Comparative Pulse Accuracy Study of Two Commercially Available Patch Insulin Infusion Pumps

Background: Patch pumps are a relatively new method of Insulin delivery. This study explores the accuracy of patch-pumps by reporting on comparative pulse-accuracy study of two patch pumps. Methods: The accuracy of two patch pumps (Cellnovo, [Cellnovo Ltd., Swansea, UK] and OmniPod^® [Ypsomed Ltd, Escrick, UK]) was evaluated micro-gravimetrically. Pulse accuracy was analysed by comparing single and time-averaged pulses for each device. Results: Single-pulses outside accuracy thresholds ±5%, ±10%, ±15%, ±20%, ±25% and ±30% were: Cellnovo; 79.6%, 55.6%, 35.0%, 19.9%, 9.7% and 4.3%; OmniPod; 86.2%, 71.6%, 57.4%, 45.5%, 35.2% and 25.4%. For 10, 20 and 40 pulse-windows mean values outside ±15% accuracy level were: Cellnovo; 7.3%, 1.5% and 0.4%, OmniPod; 37.6%, 31.8% and 25.9. Conclusions: This study showed that not all patch pumps are the same. The pumping mechanisms employed in these pumps play a significant role in the accuracy and precision of such devices.

Diabetes Technology: Uptake, Outcomes, Barriers, and the Intersection With Distress

Patients managing type 1 diabetes have access to new technologies to assist in management. This manuscript has two aims: 1) to briefly review the literature on diabetes technology use and how this relates to psychological factors and 2) to present an example of human factors research using our data to examine psychological factors associated with technology use. Device/technology uptake and use has increased over the years and at present day is a common clinical practice. There are mixed results in terms of health and psychosocial outcomes, with specific subgroups doing better than others with technology. Our data demonstrated that patients have moderately elevated diabetes distress across differing types of technology used, from low-tech to high-tech options, possibly meaning that technology does not add or take away distress. In addition, users on multiple daily injections compared to all other technology groups have less positive attitudes about technology. Finally, we discuss implications for clinical practice and future research.

Impact of insulin pump on quality of life of diabetic patients

AIM

Diabetes is an emerging health problem, both in developing and developed countries and has an enormous economic and social impact. The objective of our study was to find the impact of insulin pump on the quality of life of patients with type 2 diabetes (T2D) and compare it to the quality of life of patients with T2D using an insulin pen.

SUBJECTS AND METHODS

This is a case-control study which was conducted among patients with T2D presenting between November 2014 and November 2015. A total of 83 patients with T2D, using insulin pump were enrolled in the study as cases and 322 patients with T2D not using insulin pump but using insulin pens were enrolled as controls. Short form-36 quality of life questionnaire was used for data collection.

RESULTS

Mean age of patients using insulin pump was 52.49 ± 9.28 while the mean age of patients not using insulin pump was 54.72 ± 16.87. Mean score of all domains in the questionnaire was found to be higher in patients using insulin pump as compared to patients not using insulin pumps (P < 0.05). In 81.1% of the patients, the insulin pump decreased the frequency of hypoglycemic episodes.

CONCLUSION

Insulin pump has significantly improved the quality of life of patients in terms of better self-esteem, decreased stress, and better mood. It has resulted in improved physical health, meal time flexibility, and ease of travel. It allows patient to have more active participation in social and recreational activities improving their personal and family life.