An analysis of the short- and long-term cost-effectiveness of starting biphasic insulin aspart 30 in insulin-naïve people with poorly controlled type 2 diabetes

Burden of Illness of Type 2 Diabetes Mellitus in the Kingdom of Saudi Arabia: A Five-Year Longitudinal Study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is associated with huge clinical and economic burden in the Kingdom of Saudi Arabia (KSA) which can be curtailed by efficacious treatment. In order to achieve this, current treatment pathways for T2DM and associated costs need to be assessed.

METHODS

A longitudinal cohort review was conducted to collect country-specific and patient-specific clinical data, over a minimum observation period of 5 years in the KSA. Patient demographics, clinical characteristics and treatment patterns were recorded. The IQVIA Core Diabetes Model (CDM) version 9.5 Plus was used to assess the burden of illness, which included long-term projections of clinical (life expectancy [LE], quality-adjusted life-years [QALYs], event rates of diabetes-related complications) and direct medical cost (per-patient annual or lifelong [50 years]) outcomes of the most commonly used first-line (1st-line) regimens for T2DM from a payer perspective in the KSA.

RESULTS

Data were collected from a subpopulation of 638 patients from 15 participating centres. There was an equal gender representation with a majority of the patients belonging to Arabian/Saudi ethnicity (71.0%). Biguanides (81.5%), sulfonylureas (51.6%), dipeptidyl peptidase 4 (DPP4) inhibitors (26.2%) and fast-acting insulins (17.2%) were the most prescribed 1st-line agents. The most frequently used 1st-line regimens resulted in an estimated LE of 25-28 years, QALYs of 18-21 years and lifelong total cost of illness of 201,377-437,371 Saudi Arabian riyal (53,700-116,632 US dollars).

CONCLUSION

Our study addresses gaps in the current research by providing a complete landscape of baseline demographic, clinical characteristics and treatment patterns from a heterogeneous group of patients with T2DM in the KSA. Additionally, the burden of illness analysis using CDM showed substantially higher cost of T2DM care from a payer perspective in the KSA.

Cost-effectiveness of non-communicable disease prevention in Southeast Asia: a scoping review

Background

Cost-effectiveness analyses (CEAs) on prevention of non-communicable diseases (NCDs) are necessary to guide decision makers to allocate scarce healthcare resource, especially in Southeast Asia (SEA), where many low- and middle-income countries (LMICs) are in the process of scaling-up preventive interventions. This scoping review aims to summarize the cost-effectiveness evidence of primary, secondary, or tertiary prevention of type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVDs) as well as of major NCDs risk factors in SEA.

Methods

A scoping review was done following the PRISMA checklist for Scoping Reviews. Systematic searches were performed on Cochrane Library, EconLit, PubMed, and Web of Science to identify CEAs which focused on primary, secondary, or tertiary prevention of T2DM, CVDs and major NCDs risk factors with the focus on primary health-care facilities and clinics and conducted in SEA LMICs. Risks of bias of included studies was assessed using the Consensus of Health Economic Criteria list.

Results

This study included 42 CEAs. The interventions ranged from screening and targeting specific groups for T2DM and CVDs to smoking cessation programs, discouragement of smoking or unhealthy diet through taxation, or health education. Most CEAs were model-based and compared to a do-nothing scenario. In CEAs related to tobacco use prevention, the cost-effectiveness of tax increase was confirmed in all related CEAs. Unhealthy diet prevention, mass media campaigns, salt-reduction strategies, and tax increases on sugar-sweetened beverages were shown to be cost-effective in several settings. CVD prevention and treatment of hypertension were found to be the most cost-effective interventions. Regarding T2DM prevention, all assessed screening strategies were cost-effective or even cost-saving, and a few strategies to prevent T2DM complications were found to be cost-effective in certain settings.

Conclusion

This review shows that the cost-effectiveness of preventive strategies in SEA against T2DM, CVDs, and their major NCDs risk factors are heterogenous in both methodology as well as outcome. This review combined with the WHO "best buys" could guide LMICs in SEA in possible interventions to be considered for implementation and upscaling. However, updated and country-specific information is needed to further assess the prioritization of the different healthcare interventions.

Systematic review registration

https://osf.io, identifier: 10.17605/OSF.IO/NPEHT.

Comparative efficacy and safety of two insulin aspart formulations (Rapilin and NovoRapid) when combined with metformin, for patients with diabetes mellitus: a multicenter, randomized, open-label, controlled clinical trial

OBJECTIVE

This phase 3 confirmatory diabetes mellitus treatment study compared the safety and efficacy of Rapilin and NovoRapid insulin asparts in combination with metformin.

METHODS

This 24-week, open-label, randomized, active-controlled, noninferiority phase 3 confirmatory study conducted across centers in China aimed to enroll patients with type 2 diabetes mellitus and blood sugar glucose inadequately controlled by oral antidiabetic drugs. Randomized patients received subcutaneous mealtime Rapilin or NovoRapid (3:1) injections, with metformin. The primary objectives were to demonstrate noninferiority (margin of 0.4%) in HbA1c change from baseline and compare safety profiles of Rapilin versus NovoRapid after 24 weeks. Secondary outcomes included 2-h postprandial plasma glucose (PPG), fasting plasma glucose (FPG), and patients achieving HbA1c <7.0% and ≤6.5%.

RESULTS

590 patients with type 2 diabetes mellitus were randomized to Rapilin (n = 441) and NovoRapid (n = 149) groups. After 24 weeks, the mean HbA1c change from baseline was -2.20% (Rapilin) and -2.32% (NovoRapid); the estimated treatment difference based on least-square means was 0.04% (95% CI: -0.17, 0.26), meeting the noninferiority criteria for Rapilin versus NovoRapid. Comparable improvements were reported for mean 2-hour PPG (6.14 and 6.29 mmol/L), FPG (2.02 and 1.70 mmol/L), and patients with HbA1c <7.0% (52.6% and 51.0%) and ≤6.5% (34.2% and 30.9%), in the Rapilin and NovoRapid groups, respectively, with no significant safety or immunogenicity outcome differences.

CONCLUSIONS

Rapilin demonstrated non-inferior glycemic control, and matching safety and immunogenicity to NovoRapid in patients with type 2 diabetes mellitus also receiving metformin over 24 weeks.

TRIAL REGISTRATION

ChiCTR20003129041.

Disease-Related Costs Published in The Middle East and North Africa Region: Systematic Review and Analysis of Transferability

BACKGROUND

In the Middle East and North Africa (MENA) the scarcity of local cost data is a key barrier to conducting health economic evaluations. We systematically reviewed reports of disease-related costs from MENA and analysed their transferability within the region.

METHODS

We searched PubMed and included full text English papers that reported disease-related costs from the local populations of Algeria, Bahrain, Egypt, Iraq, Jordan, Saudi Arabia, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Syria, Tunisia, United Arab Emirates and Yemen between 1995 and 2019. Screening, study selection and data extraction were done in duplicate. Study-related variables, costing methods, all costs and their characteristics were extracted and analysed via descriptive methods. From multi-country studies of MENA employing homogenous costing methods, we estimated the ratio (cost transfer coefficient) between the relative differences in direct medical costs and macroeconomic indicators via robust regression. We predicted each cost via the estimated cost transfer formula and evaluated prediction error between true and predicted (transferred) costs.

RESULTS

The search yielded 1646 records, 206 full text papers and 3525 costs from 84 diagnoses. Transferability was analysed involving 144 direct medical costs from eight multi-country studies. Adjusting the average of available foreign costs by 0.28 times the relative difference in GDP per capita provided the most accurate estimates. The correlation between true and predicted costs was 0.96; 68% of predicted costs fell in the true ± 50% range. Predictions were more accurate for costs from studies that involved the largest number of countries, for countries outside the Gulf region and for drug costs versus unit or disease costs.

CONCLUSION

The estimated cost transfer formula allows the prediction of missing costs in MENA if only GDP per capita is available for adjustment to the local setting. Input costs for the formula should be collected from multiple sources and match the decision situation.

A Systematic Review on Economic Evaluation Studies of Diagnostic and Therapeutic Interventions in the Middle East and North Africa

INTRODUCTION

Due to the increase in healthcare budget constraint, economic evaluation (EE) evidence is increasingly required to inform resource allocation decisions. This study aimed to systematically review quantity, characteristics, and quality of full EE studies on diagnostic and therapeutic interventions conducted in 26 Middle East and North Africa (MENA) countries.

METHODS

PubMed and Scopus databases were comprehensively searched to identify the published EE studies in the MENA region. The quality of reviewed studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The search identified 69 studies. The cost-utility approach was adopted in 49 studies (71 %). More than half (38 studies; 55 %) were conducted in Iran and Turkey. Sixteen countries (62 %) did not have any EE studies. The most frequently analyzed therapeutic areas were infectious diseases (19 studies; 28 %), cardiovascular diseases (11 studies; 16 %), and malignancies (10 studies; 14 %). Ten studies (14 %), 46 (67 %), 12 (17 %), and 1 study (1 %) were classified as excellent, high, moderate, and poor quality, respectively. The mean of items reported was 85.10 % (standard deviation 13.32 %). Characterizing heterogeneity, measurement of effectiveness, time horizon, and discount rate were missed in 21 (60 %), 22 (32 %), 20 (29 %) and 15 (25 %) studies, respectively. Data on effectiveness and utility relied primarily on studies conducted outside the region.

CONCLUSIONS

The quantity of EE studies in the MENA region remains low; however, overall quality is high to excellent. The availability of local data, capacity building, and national guidelines are vital to improve both the quantity and quality of EE studies in the region.

Cost-Effectiveness of Preoperative Spinal Imaging Before Total Hip Arthroplasty

BACKGROUND

The risk of instability, dislocation, and revision following total hip arthroplasty (THA) is increased in patients with abnormal spinopelvic mobility. Seated and standing lateral lumbar spine imaging can identify patients with stiff/hypermobile spine (SHS) to guide interventions such as changes in acetabular cup placement or use of a dual-mobility hip construct aimed at reducing dislocation risk.

METHODS

A Markov decision model was created to compare routine preoperative spinal imaging (PSI) to no screening in patients with and without SHS. Screened patients with SHS were assumed to receive dual-mobility hardware while those without SHS and nonscreened patients were assumed to receive conventional THA. Cost-effectiveness was determined by estimating the incremental cost-effectiveness ratio. Effectiveness measured as quality-adjusted life years (QALYs), with $100,000 per additional QALY as the threshold for cost-effectiveness. Sensitivity analyses were performed to determine the robustness of the base-case result.

RESULTS

The screening strategy with PSI had a lifetime cost of $12,515 and QALY gains of 16.91 compared with no-screening ($13,331 and 16.77). The PSI strategy reached cost-effectiveness at 5 years and was dominant (ie, less costly and more effective) at 11 years following THA. In sensitivity analyses, PSI remained the dominant strategy if prevalence of SHS was >1.9%, the cost of PSI was <$925, and the cost of dual-mobility hardware exceeded the cost of conventional hardware by <$2850.

CONCLUSION

Screening patients for SHS prior to THA with PSI is both less costly and more effective and should be considered as part of standard presurgical workup.

The state of cost-utility analysis in India: A systematic review

Aims:

Cost-utility studies are crucial tools that help policy-makers promote appropriate resource allocation. The objective of this study was to evaluate the extent and quality of cost-utility analysis (CUA) in India through a systematic literature review.

Methods:

Comprehensive database search was conducted to identify the relevant literature published from November 2009 to November 2019. Gray literature and hand searches were also performed. Two researchers independently reviewed and assessed study quality using Consolidated Health Economic Evaluation Reporting Standards checklist.

Results:

Thirty-five studies were included in the final review. Thirteen studies used Markov model, five used decision tree model, four used a combination of decision tree and Markov model and one each used microsimulation and dynamic compartmental model. The primary therapeutic areas targeted in CUA were infectious diseases (n = 12), ophthalmology (n = 5), and endocrine disorders (n = 4). Five studies were carried out in Tamil Nadu, four in Goa, three in Punjab, two each in Delhi, Maharashtra, and Uttar Pradesh, and one each in West Bengal and Karnataka. Twenty-three, eight, and four studies were found to be of excellent, very good, and good quality, respectively. The average quality score of the studies was 19.21 out of 24.

Conclusions:

This systematic literature review identified the published CUA studies in India. The overall quality of the included studies was good; however, features such as subgroup analyses and explicit study perspective were missing in several evaluations.

A Systematic Review of Sources of Outcomes and Cost Data Utilized in Economic Evaluation Research Conducted in the Gulf Cooperation Council

Background

Transparency and clarity in reporting of methods used to identify, measure, and value outcomes and resources in published economic evaluations is crucial.

Objective

The aims of this review were to identify and assess the quality of published economic evaluation studies in the Gulf Cooperation Council (GCC) region, with a specific focus on methods used to identify, measure, and value cost and outcomes data.

Methods

An electronic search of publications from 2009 to October 2019 was performed in three clinical (Medline, Scopus, and EMBASE) and one economic (NHS EED) databases. Full economic evaluations undertaken in GCC countries from any perspective were included. Reference lists of three reviews on the same topic and area were also searched for further eligible articles. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for methodological quality assessment. Data on type and source of cost and outcomes data were collected.

Results

Out of 1857 studies identified, 14 relevant studies were eligible and included. Eleven studies were based in Saudi Arabia, and the remaining studies were published in the United Arab of Emirates (UAE), Qatar, and Oman. Majority of the evaluations were based on the Markov modelling (n=8). None of the studies fully fulfilled the CHEERS quality criteria. Quality-adjusted life years (QALYs) was the main outcome (n=10). The EQ-5D was valued using the UK value set tariff (n=6). Published literature was the source of outcomes data in seven studies. Hospital-based data were used as a source of healthcare resource use data in four studies, whereas hospital-based costs (n = 7) combined with other sources such as local/national data were the sources of unit cost data in the majority of the studies.

Conclusion

Rigorous economic evaluations are lacking in the region leading to inaccurate information being given to decision-makers.

Costs associated with management of non-communicable diseases in the Arab Region: a scoping review

BACKGROUND

Global mortality rates resulting from non-communicable diseases (NCDs) are reaching alarming levels, especially in low- and middle-income countries, imposing a considerable burden on individuals and health systems as a whole. This scoping review aims at synthesizing the existing literature evaluating the cost associated with the management and treatment of major NCDs across all Arab countries; at evaluating the quality of these studies; and at identifying the gap in existing literature.

METHODS

A systematic search was conducted using Medline electronic database to retrieve articles evaluating costs associated with management of NCDs in Arab countries, published in English between January 2000 and April 2016. 55 studies met the eligibility criteria and were independently screened by two reviewers who extracted/calculated the following information: country, theme (management of NCD, treatment/medication, or procedure), study design, setting, population/sample size, publication year, year for cost data cost conversion (US$), costing approach, costing perspective, type of costs, source of information and quality evaluation using the Newcastle-Ottawa Scale (NOS).

RESULTS

The reviewed articles covered 16 countries in the Arab region. Most of the studies were observational with a retrospective or prospective design, with a relatively low to very low quality score. Our synthesis revealed that NCDs' management costs in the Arab region are high; however, there is a large variation in the methods used to quantify the costs of NCDs in these countries, making it difficult to conduct any type of comparisons.

CONCLUSIONS

The findings revealed that data on the direct costs of NCDs remains limited by the paucity of this type of evidence and the generally low quality of studies published in this area. There is a need for future studies, of improved and harmonized methodology, as such evidence is key for decision-makers and directs health care planning.

Novel Risk Engine for Diabetes Progression and Mortality in USA: Building, Relating, Assessing, and Validating Outcomes (BRAVO)

BACKGROUND

There is an urgent need to update diabetes prediction, which has relied on the United Kingdom Prospective Diabetes Study (UKPDS) that dates back to 1970 s' European populations.

OBJECTIVE

The objective of this study was to develop a risk engine with multiple risk equations using a recent patient cohort with type 2 diabetes mellitus reflective of the US population.

METHODS

A total of 17 risk equations for predicting diabetes-related microvascular and macrovascular events, hypoglycemia, mortality, and progression of diabetes risk factors were estimated using the data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial (n = 10,251). Internal and external validation processes were used to assess performance of the Building, Relating, Assessing, and Validating Outcomes (BRAVO) risk engine. One-way sensitivity analysis was conducted to examine the impact of risk factors on mortality at the population level.

RESULTS

The BRAVO risk engine added several risk factors including severe hypoglycemia and common US racial/ethnicity categories compared with the UKPDS risk engine. The BRAVO risk engine also modeled mortality escalation associated with intensive glycemic control (i.e., glycosylated hemoglobin < 6.5%). External validation showed a good prediction power on 28 endpoints observed from other clinical trials (slope = 1.071, R² = 0.86).

CONCLUSION

The BRAVO risk engine for the US diabetes cohort provides an alternative to the UKPDS risk engine. It can be applied to assist clinical and policy decision making such as cost-effective resource allocation in USA.

15 Years of Experience with Biphasic Insulin Aspart 30 in Type 2 Diabetes

Since clinical experience with biphasic insulin aspart 30 (BIAsp 30) in type 2 diabetes mellitus (T2DM) was reviewed in 2012 after 10 years of use worldwide, additional studies have been published that highlight new aspects, including use in real-world populations. Evidence from 35 new studies confirms and builds upon previous work indicating that BIAsp 30 continues to have pharmacodynamic and clinical advantages over biphasic human insulin (BHI 30), including in real-world practice with unselected populations of patients. BIAsp 30 has also been shown to be safe and efficacious as an add-on to dipeptidyl peptidase-4 (DPP-4) inhibitors. Intensification with BIAsp 30 is a safe and effective way to improve glycemic control, and titration performed by patients can achieve results that are at least comparable to those when being guided by healthcare providers. Stepwise intensification using BIAsp 30 is comparable to intensification using a basal–bolus regimen, and twice-daily BIAsp 30 provides similar glycemic control to a basal-plus regimen. Data from large observational studies, in particular, have identified patient-related characteristics that are associated with improved clinical responses, suggesting that earlier initiation and intensification of therapy is warranted. Finally, new health-economic analyses continue to confirm that BIAsp 30 is cost effective versus other therapies such as BHI 30, neutral protamine Hagedorn (NPH), or insulin glargine in both insulin-naïve and insulin-experienced patients. After 15 years of clinical use worldwide, analysis of more recent 5-year data indicates that BIAsp 30 remains a safe, effective, and simple-to-use insulin for initiation and intensification by diabetes specialists and primary care physicians in a variety of patients with T2DM.

Economic Studies on Non-Communicable Diseases and Injuries in India: A Systematic Review

BACKGROUND

The burden from non-communicable diseases and injuries (NCDI) in India is increasing rapidly. With low public sector investment in the health sector generally, and a high financial burden on households for treatment, it is important that economic evidence is used to set priorities in the context of NCDI.

OBJECTIVE

Our objective was to understand the extent to which economic analysis has been used in India to (1) analyze the impact of NCDI and (2) evaluate prevention and treatment interventions. Specifically, this analysis focused on the type of economic analysis used, disease categories, funding patterns, authorship, and author characteristics.

METHODS

We conducted a systematic review based on economic keywords to identify studies on NCDI in India published in English between January 2006 and November 2016. In all, 96 studies were included in the review. The analysis used descriptive statistics, including frequencies and percentages.

RESULTS

A majority of the studies were economic impact studies, followed by economic evaluation studies, especially cost-effectiveness analysis. In the costing/partial economic evaluation category, most were cost-description and cost-analysis studies. Under the economic impact/economic burden category, most studies investigated out-of-pocket spending. The studies were mostly on cardiovascular disease, diabetes, and neoplasms. Slightly over half of the studies were funded, with funding coming mainly from outside of India. Half of the studies were led by domestic authors. In most of the studies, the lead author was a clinician or a public health professional; however, most of the economist-led studies were by authors from outside India.

CONCLUSIONS

The results indicate the lack of engagement of economists generally and health economists in particular in research on NCDI in India. Demand from health policy makers for evidence-based decision making appears to be lacking, which in turn solidifies the divergence between economics and health policy, and highlights the need to prioritize scarce resources based on evidence regarding what works. Capacity building in health economics needs focus, and the government's support in this is recommended.

Quality of life of the Indonesian general population: Test-retest reliability and population norms of the EQ-5D-5L and WHOQOL-BREF

Objectives

The objective of this study is to obtain population norms and to assess test-retest reliability of EQ-5D-5L and WHOQOL-BREF for the Indonesian population.

Methods

A representative sample of 1056 people aged 17–75 years was recruited from the Indonesian general population. We used a multistage stratified quota sampling method with respect to residence, gender, age, education level, religion and ethnicity. Respondents completed EQ-5D-5L and WHOQOL-BREF with help from an interviewer. Norms data for both instruments were reported. For the test-retest evaluations, a sub-sample of 206 respondents completed both instruments twice.

Results

The total sample and test-retest sub-sample were representative of the Indonesian general population. The EQ-5D-5L shows almost perfect agreement between the two tests (Gwet’s AC: 0.85–0.99 and percentage agreement: 90–99%) regarding the five dimensions. However, the agreement of EQ-VAS and index scores can be considered as poor (ICC: 0.45 and 0.37 respectively). For the WHOQOL-BREF, ICCs of the four domains were between 0.70 and 0.79, which indicates moderate to good agreement. For EQ-5D-5L, it was shown that female and older respondents had lower EQ-index scores, whilst rural, younger and higher-educated respondents had higher EQ-VAS scores. For WHOQOL-BREF: male, younger, higher-educated, high-income respondents had the highest scores in most of the domains, overall quality of life, and health satisfaction.

Conclusions

This study provides representative estimates of self-reported health status and quality of life for the general Indonesian population as assessed by the EQ-5D-5L and WHOQOL-BREF instruments. The descriptive system of the EQ-5D-5L and the WHOQOL-BREF have high test-retest reliability while the EQ-VAS and the index score of EQ-5D-5L show poor agreement between the two tests. Our results can be useful to researchers and clinicians who can compare their findings with respect to these concepts with those of the Indonesian general population.

How Consistent is the Relationship between Improved Glucose Control and Modelled Health Outcomes for People with Type 2 Diabetes Mellitus? a Systematic Review

BACKGROUND

There are an increasing number of studies using simulation models to conduct cost-effectiveness analyses for type 2 diabetes mellitus.

OBJECTIVE

To evaluate the relationship between improvements in glycosylated haemoglobin (HbA_1c) and simulated health outcomes in type 2 diabetes cost-effectiveness studies.

METHODS

A systematic review was conducted on MEDLINE and EMBASE to collect cost-effectiveness studies using type 2 diabetes simulation models that reported modelled health outcomes of blood glucose-related interventions in terms of quality-adjusted life-years (QALYs) or life expectancy (LE). The data extracted included information used to characterise the study cohort, the intervention's treatment effects on risk factors and model outcomes. Linear regressions were used to test the relationship between the difference in HbA_1c (∆HbA_1c) and incremental QALYs (∆QALYs) or LE (∆LE) of intervention and control groups. The ratio between the ∆QALYs and ∆LE was calculated and a scatterplot between the ratio and ∆HbA_1c was used to explore the relationship between these two.

RESULTS

Seventy-six studies were included in this research, contributing to 124 pair of comparators. The pooled regressions indicated that the marginal effect of a 1% HbA_1c decrease in intervention resulted in an increase in life-time QALYs and LE of 0.371 (95% confidence interval 0.286-0.456) and 0.642 (95% CI 0.494-0.790), respectively. No evidence of heterogeneity between models was found. An inverse exponential relationship was found and fitted between the ratio (∆QALY/∆LE) and ∆HbA_1c.

CONCLUSION

There is a consistent relationship between ∆HbA_1c and ∆QALYs or ∆LE in cost-effectiveness analyses using type 2 diabetes simulation models. This relationship can be used as a diagnostic tool for decision makers.

Systematic Review of the Cost Effectiveness of Insulin Analogues in Type 1 and Type 2 Diabetes Mellitus

BACKGROUND

Insulin analogues have a pharmacokinetic advantage over human insulin and are increasingly used to treat diabetes mellitus. A summary of their cost effectiveness versus other available treatments was required.

OBJECTIVE

Our objective was to systematically review the published cost-effectiveness studies of insulin analogues for the treatment of patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM).

METHODS

We searched major databases and health technology assessment agency reports for economic evaluation studies published up until 30 September 2015. Two reviewers performed data extraction and assessed the quality of the data using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines.

RESULTS

Seven of the included studies assessed short-acting insulin analogues, 12 assessed biphasic insulin analogues, 30 assessed long-acting insulin analogues and one assessed a combination of short- and long-acting insulin analogues. Only 17 studies involved patients with T1DM, all were modelling studies and 12 were conducted in Canada. The incremental cost-effectiveness ratios (ICERs) for short-acting insulin analogues ranged from dominant to $US435,913 per quality-adjusted life-year (QALY) gained, the ICERs for biphasic insulin analogues ranged from dominant to $US57,636 per QALY gained and the ICERs for long-acting insulin analogues ranged from dominant to $US599,863 per QALY gained. A total of 15 studies met all the CHEERS guidelines reporting quality criteria. Only 26 % of the studies assessed heterogeneity in their analyses.

CONCLUSION

Current evidence indicates that insulin analogues are cost effective for T1DM; however, evidence for their use in T2DM is not convincing. Additional evidence regarding compliance and efficacy is required to support the broader use of long-acting and biphasic insulin analogues in T2DM. The value of insulin analogues depends strongly on reductions in hypoglycaemia event rates and its efficacy in lowering glycated haemoglobin (HbA_1c).