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de Jong LA, Li X, Emamipour S, van der Werf S, Postma MJ, van Dijk PR, Feenstra TL. Evaluating the Cost-Utility of Continuous Glucose Monitoring in Individuals with Type 1 Diabetes: A Systematic Review of the Methods and Quality of Studies Using Decision Models or Empirical Data. PHARMACOECONOMICS 2024:10.1007/s40273-024-01388-6. [PMID: 38904911 DOI: 10.1007/s40273-024-01388-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION This review presents a critical appraisal of differences in the methodologies and quality of model-based and empirical data-based cost-utility studies on continuous glucose monitoring (CGM) in type 1 diabetes (T1D) populations. It identifies key limitations and challenges in health economic evaluations on CGM and opportunities for their improvement. METHODS The review and its documentation adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. Searches for articles published between January 2000 and January 2023 were conducted using the MEDLINE, Embase, Web of Science, Cochrane Library, and Econlit databases. Published studies using models and empirical data to evaluate the cost utility of all CGM devices used by T1D patients were included in the search. Two authors independently extracted data on interventions, populations, model settings (e.g., perspectives and time horizons), model types and structures, clinical outcomes used to populate the model, validation, and uncertainty analyses. They subsequently met to confirm consensus. Quality was assessed using the Philips checklist for model-based studies and the Consensus Health Economic Criteria (CHEC) checklist for empirical studies. Model validation was assessed using the Assessment of the Validation Status of Health-Economic decision models (AdViSHE) checklist. The extracted data were used to generate summary tables and figures. The study protocol is registered with PROSPERO (CRD42023391284). RESULTS In total, 34 studies satisfied the selection criteria, two of which only used empirical data. The remaining 32 studies applied 10 different models, with a substantial majority adopting the CORE Diabetes Model. Model-based studies often lacked transparency, as their assumptions regarding the extrapolation of treatment effects beyond available evidence from clinical studies and the selection and processing of the input data were not explicitly stated. Initial scores for disagreements concerning checklists were relatively high, especially for the Philips checklist. Following their resolution, overall quality scores were moderate at 56%, whereas model validation scores were mixed. Strikingly, costing approaches differed widely across studies, resulting in little consistency in the elements included in intervention costs. DISCUSSION AND CONCLUSION The overall quality of studies evaluating CGM was moderate. Potential areas of improvement include developing systematic approaches for data selection, improving uncertainty analyses, clearer reporting, and explaining choices for particular modeling approaches. Few studies provided the assurance that all relevant and feasible options had been compared, which is required by decision makers, especially for rapidly evolving technologies such as CGM and insulin administration. High scores for disagreements indicated that several checklists contained questions that were difficult to interpret consistently for quality assessment. Therefore, simpler but comprehensive quality checklists may be needed for model-based health economic evaluation studies.
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Affiliation(s)
- Lisa A de Jong
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Xinyu Li
- Groningen Research Institute of Pharmacy (GRIP), Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
| | - Sajad Emamipour
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sjoukje van der Werf
- Central Medical Library, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Peter R van Dijk
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Diabetes Center, Isala, Zwolle, The Netherlands
| | - Talitha L Feenstra
- Groningen Research Institute of Pharmacy (GRIP), Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands.
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
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Mathieu C, Ahmed W, Gillard P, Cohen O, Vigersky R, de Portu S, Ozdemir Saltik AZ. The Health Economics of Automated Insulin Delivery Systems and the Potential Use of Time in Range in Diabetes Modeling: A Narrative Review. Diabetes Technol Ther 2024; 26:66-75. [PMID: 38377319 DOI: 10.1089/dia.2023.0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Intensive therapy with exogenous insulin is the treatment of choice for individuals living with type 1 diabetes (T1D) and some with type 2 diabetes, alongside regular glucose monitoring. The development of systems allowing (semi-)automated insulin delivery (AID), by connecting glucose sensors with insulin pumps and algorithms, has revolutionized insulin therapy. Indeed, AID systems have demonstrated a proven impact on overall glucose control, as indicated by effects on glycated hemoglobin (HbA1c), risk of severe hypoglycemia, and quality of life measures. An alternative endpoint for glucose control that has arisen from the use of sensor-based continuous glucose monitoring is the time in range (TIR) measure, which offers an indication of overall glucose control, while adding information on the quality of control with regard to blood glucose level stability. A review of literature on the health-economic value of AID systems was conducted, with a focus placed on the growing place of TIR as an endpoint in studies involving AID systems. Results showed that the majority of economic evaluations of AID systems focused on individuals with T1D and found AID systems to be cost-effective. Most studies incorporated HbA1c, rather than TIR, as a clinical endpoint to determine treatment effects on glucose control and subsequent quality-adjusted life year (QALY) gains. Likely reasons for the choice of HbA1c as the chosen endpoint is the use of this metric in most validated and established economic models, as well as the limited publicly available evidence on appropriate methodologies for TIR data incorporation within conventional economic evaluations. Future studies could include the novel TIR metric in health-economic evaluations as an additional measure of treatment effects and subsequent QALY gains, to facilitate a holistic representation of the impact of AID systems on glycemic control. This would provide decision makers with robust evidence to inform future recommendations for health care interventions.
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Affiliation(s)
- Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, Leuven, Belgium
| | - Waqas Ahmed
- Covalence Research Ltd, Harpenden, United Kingdom
| | - Pieter Gillard
- Department of Endocrinology, UZ Gasthuisberg, Leuven, Belgium
| | - Ohad Cohen
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | - Simona de Portu
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
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Sherr JL, Schoelwer M, Dos Santos TJ, Reddy L, Biester T, Galderisi A, van Dyk JC, Hilliard ME, Berget C, DiMeglio LA. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes technologies: Insulin delivery. Pediatr Diabetes 2022; 23:1406-1431. [PMID: 36468192 DOI: 10.1111/pedi.13421] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Melissa Schoelwer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Leenatha Reddy
- Department of Pediatrics Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Torben Biester
- AUF DER BULT, Hospital for Children and Adolescents, Hannover, Germany
| | - Alfonso Galderisi
- Department of Woman and Child's Health, University of Padova, Padova, Italy
| | | | - Marisa E Hilliard
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Cari Berget
- Barbara Davis Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Jiao Y, Lin R, Hua X, Churilov L, Gaca MJ, James S, Clarke PM, O'Neal D, Ekinci EI. A systematic review: Cost-effectiveness of continuous glucose monitoring compared to self-monitoring of blood glucose in type 1 diabetes. Endocrinol Diabetes Metab 2022; 5:e369. [PMID: 36112608 PMCID: PMC9659662 DOI: 10.1002/edm2.369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/19/2022] [Accepted: 08/28/2022] [Indexed: 12/15/2022] Open
Abstract
Continuous glucose monitoring (CGM) is rapidly becoming a vital tool in the management of type 1 diabetes. Its use has been shown to improve glycaemic management and reduce the risk of hypoglycaemic events. The cost of CGM remains a barrier to its widespread application. We aimed to identify and synthesize evidence about the cost-effectiveness of utilizing CGM in patients with type 1 diabetes. Studies were identified from MEDLINE, Embase and Cochrane Library from January 2010 to February 2022. Those that assessed the cost-effectiveness of CGM compared to self-monitored blood glucose (SMBG) in patients with type 1 diabetes and reported lifetime incremental cost-effectiveness ratio (ICER) were included. Studies on critically ill or pregnant patients were excluded. Nineteen studies were identified. Most studies compared continuous subcutaneous insulin infusion and SMBG to a sensor-augmented pump (SAP). The estimated ICER range was [$18,734-$99,941] and the quality-adjusted life year (QALY) gain range was [0.76-2.99]. Use in patients with suboptimal management or greater hypoglycaemic risk revealed more homogenous results and lower ICERs. Limited studies assessed CGM in the context of multiple daily injections (MDI) (n = 4), MDI and SMBG versus SAP (n = 2) and three studies included hybrid closed-loop systems. Most studies (n = 17) concluded that CGM is a cost-effective tool. This systematic review suggests that CGM appears to be a cost-effective tool for individuals with type 1 diabetes. Cost-effectiveness is driven by reducing short- and long-term complications. Use in patients with suboptimal management or at risk of severe hypoglycaemia is most cost-effective.
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Affiliation(s)
- Yuxin Jiao
- Austin HealthHeidelbergVictoriaAustralia
| | - Rose Lin
- Austin HealthHeidelbergVictoriaAustralia
| | - Xinyang Hua
- Centre for Health PolicyMelbourne School of Population and Global HealthUniversity of MelbourneCarltonVictoriaAustralia
| | - Leonid Churilov
- Melbourne Medical SchoolThe University of MelbourneParkvilleVictoriaAustralia
| | - Michele J. Gaca
- Health Sciences LibraryAustin HealthHeidelbergVictoriaAustralia
| | - Steven James
- School of Nursing, Midwifery and ParamedicineUniversity of the Sunshine CoastPetrieQueenslandAustralia
| | - Philip M. Clarke
- Health Economics Research CentreNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - David O'Neal
- Department of MedicineSt Vincent's Hospital Melbourne, Melbourne Medical School, The University of MelbourneParkvilleVictoriaAustralia
| | - Elif I. Ekinci
- Department of Medicine, Austin HealthMelbourne Medical School, The University of MelbourneParkvilleVictoriaAustralia,Department of EndocrinologyAustin HealthHeidelbergVictoriaAustralia
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Evin F, Ata A, Er E, Demir G, Çetin H, Altınok YA, Özen S, Darcan Ş, Gökşen D. Predictive low-glucose suspend system and glycemic variability. Int J Diabetes Dev Ctries 2022. [DOI: 10.1007/s13410-021-00957-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Grunberger G, Sherr J, Allende M, Blevins T, Bode B, Handelsman Y, Hellman R, Lajara R, Roberts VL, Rodbard D, Stec C, Unger J. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract 2021; 27:505-537. [PMID: 34116789 DOI: 10.1016/j.eprac.2021.04.008] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders. METHODS The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development. MAIN OUTCOME MEASURES Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range. RESULTS This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base. RECOMMENDATIONS Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology. CONCLUSIONS Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.
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Affiliation(s)
| | - Jennifer Sherr
- Yale University School of Medicine, New Haven, Connecticut
| | - Myriam Allende
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, Georgia
| | | | - Richard Hellman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - David Rodbard
- Biomedical Informatics Consultants, LLC, Potomac, Maryland
| | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | - Jeff Unger
- Unger Primary Care Concierge Medical Group, Rancho Cucamonga, California
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Pease A, Zomer E, Liew D, Earnest A, Soldatos G, Ademi Z, Zoungas S. Cost-Effectiveness Analysis of a Hybrid Closed-Loop System Versus Multiple Daily Injections and Capillary Glucose Testing for Adults with Type 1 Diabetes. Diabetes Technol Ther 2020; 22:812-821. [PMID: 32348159 DOI: 10.1089/dia.2020.0064] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Hybrid closed-loop systems may offer improved HbA1c levels, more time-in-range, and less hypoglycemia than alternative treatment strategies. However, it is unclear if glycemic improvements offset this technology's higher acquisition costs. Among adults with type 1 diabetes in Australia, we sought to evaluate the cost-effectiveness of a hybrid closed-loop system in comparison with the current standard of care, comprising insulin injections and capillary glucose testing. Methods: Cost-effectiveness analysis was performed using decision analysis in combination with a Markov model to simulate disease progression in a cohort of adults with type 1 diabetes and compare the downstream health and economic consequences of hybrid closed-loop therapy versus current standard of care. Transition probabilities and utilities were sourced from published studies. Costs were considered from the perspective of the Australian health care system. A lifetime horizon was considered, with annual discount rates of 5% applied to future costs and outcomes. Uncertainty was assessed with probabilistic and deterministic sensitivity analyses. Results: Use of a hybrid closed-loop system resulted in an incremental cost-effectiveness ratio of Australian dollars (AUD) 37,767 per quality-adjusted life year (QALY) gained. This is below the traditionally cited willingness to pay a threshold of $50,000 per QALY gained in the Australian setting. Sensitivity analyses that varied baseline glycemic control, treatment effects, technology costs, age, discount rates, and time horizon indicated the results to be robust. Conclusions: For adults with type 1 diabetes, hybrid closed-loop therapy is likely to be cost-effective compared with multiple daily injections and capillary glucose testing in Australia.
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Affiliation(s)
- Anthony Pease
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Georgia Soldatos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Alfred Health, Melbourne, Australia
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Affiliation(s)
- Bruce W Bode
- 1 Atlanta Diabetes Associates, Atlanta, and Emory University, School of Medicine, Atlanta, GA
| | - Tadej Battelino
- 2 University Medical Center-University Children's Hospital Ljubljana, Ljubljana, Slovenia
- 3 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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