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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Diabetes Care 2023; 46:e151-e199. [PMID: 37471273 PMCID: PMC10516260 DOI: 10.2337/dci23-0036] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/11/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B. Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA
| | - George L. Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, IL
| | - David E. Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA
| | - Andrea R. Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E. Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL
| | - David M. Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA
| | - M. Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Clin Chem 2023:hvad080. [PMID: 37473453 DOI: 10.1093/clinchem/hvad080] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association of Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (Hb A1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of Hb A1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA, United States
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, ILUnited States
| | - David E Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA, United States
| | - Andrea R Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL, United States
| | - David M Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - M Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
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Rotondi MA, Wong O, Riddell M, Perkins B. Population-Level Impact and Cost-effectiveness of Continuous Glucose Monitoring and Intermittently Scanned Continuous Glucose Monitoring Technologies for Adults With Type 1 Diabetes in Canada: A Modeling Study. Diabetes Care 2022; 45:2012-2019. [PMID: 35834175 PMCID: PMC9472499 DOI: 10.2337/dc21-2341] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 06/07/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Maintaining healthy glucose levels is critical for the management of type 1 diabetes (T1D), but the most efficacious and cost-effective approach (capillary self-monitoring of blood glucose [SMBG] or continuous [CGM] or intermittently scanned [isCGM] glucose monitoring) is not clear. We modeled the population-level impact of these three glucose monitoring systems on diabetes-related complications, mortality, and cost-effectiveness in adults with T1D in Canada. RESEARCH DESIGN AND METHODS We used a Markov cost-effectiveness model based on nine complication states for adults aged 18-64 years with T1D. We performed the cost-effectiveness analysis from a single-payer health care system perspective over a 20-year horizon, assuming a willingness-to-pay threshold of CAD 50,000 per quality-adjusted life-year (QALY). Primary outcomes were the number of complications and deaths and the incremental cost-effectiveness ratio (ICER) of CGM and isCGM relative to SMBG. RESULTS An initial cohort of 180,000 with baseline HbA1c of 8.1% was used to represent all Canadians aged 18-64 years with T1D. Universal SMBG use was associated with ∼11,200 people (6.2%) living without complications and ∼89,400 (49.7%) deaths after 20 years. Universal CGM use was associated with an additional ∼7,400 (4.1%) people living complications free and ∼11,500 (6.4%) fewer deaths compared with SMBG, while universal isCGM use was associated with ∼3,400 (1.9%) more people living complications free and ∼4,600 (2.6%) fewer deaths. Relative to SMBG, CGM and isCGM had ICERs of CAD 35,017/QALY and 17,488/QALY, respectively. CONCLUSIONS Universal use of CGM or isCGM in the Canadian T1D population is anticipated to reduce diabetes-related complications and mortality at an acceptable cost-effectiveness threshold.
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Affiliation(s)
- Michael A Rotondi
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Octavia Wong
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Michael Riddell
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Bruce Perkins
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Canada
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Moriuchi T, Otaki Y, Satou H, Chai F, Hayashida Y, Aikawa R, Sugiyama T, Sode K. Clinical Study of a High Accuracy Green Design Blood Glucose Monitor Using an Innovative Optical Transmission Absorbance System. J Diabetes Sci Technol 2022; 16:1069-1075. [PMID: 34889119 PMCID: PMC9445325 DOI: 10.1177/19322968211060865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Blood glucose monitoring (BGM) is essential for glycemic control in diabetic therapy. Followingly, accurate sensors are required for both daily personal and clinical use. The frequency of sensor use in patients with diabetes facilitates the use of disposable components. However, BGM systems are not exempt from green innovation sustainability initiatives. METHODS Clinical study of a high-accuracy green design blood glucose monitor using an innovative optical transmission absorbance system was carried out. Venous blood samples were collected from 104 patients with type II diabetes. The heat resistance of sensor strips was evaluated by storing sensor strips at 25℃ and 60℃ for approximately 3 months. Accuracy of the BGM system was evaluated via the ISO 15197:2013 protocol. RESULTS The BGM system achieved ±7.1% accuracy in glycemic level measurement, with 84% of all measurements within ±5% of the reference values. Furthermore, the sensor strip demonstrated heat resistance for more than 3 months when stored at 60℃. CONCLUSIONS A new, highly accurate BGM system was developed based on the latest optical measurement system, introducing a rare metal-free "green-strip." The developed BGM system achieved the highest reported accuracy in clinical research, using venous blood from patients with diabetes. The sensor strip also exhibited high heat resistance, reducing limitations on storage conditions.
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Affiliation(s)
| | | | | | | | | | | | | | - Koji Sode
- Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC, USA
- Koji Sode, PhD, Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC 27599, USA.
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Nuijten M, Dainelli L, Rasouli B, Araujo Torres K, Perugini M, Marczewska A. A Meal Replacement Program for the Treatment of Obesity: A Cost-Effectiveness Analysis from the Swiss Payer's Perspective. Diabetes Metab Syndr Obes 2021; 14:3147-3160. [PMID: 34267531 PMCID: PMC8275158 DOI: 10.2147/dmso.s284855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/04/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Obesity is a disease associated with high direct medical costs and high indirect costs resulting from productivity loss. The high prevalence of obesity generates the need for payers to identify cost-effective weight loss approaches. Among various weight management techniques, the OPTI (Optifast®) program is a clinically recognised total meal replacement diet that can lead to significant weight loss and reduction in complications. This study's objective is to assess OPTI program's cost-effectiveness in Switzerland in comparison to "no intervention" and pharmacotherapy. METHODS An event-driven decision-analytic model was used to estimate the payer's cost savings through the reimbursement of OPTI program over a 1-year period as well as a lifetime in Switzerland. The analysis was performed on a broad population of people with obesity with a body mass index (BMI) higher than 30 kg/m2 following the OPTI program vs two comparators (liraglutide and "no intervention"). The model incorporated a higher risk of complications due to an increased BMI and their related healthcare costs. Data sources included published literature, clinical trials, official Swiss price/tariff lists and national population statistics. The primary perspective was that of a Swiss payer. Scenario analyses - for example, for patients with existing complications (such as myocardial infarction, stroke, type 2 diabetes mellitus) or severe obesity - were conducted to test the robustness of the results. RESULTS The OPTI program results in cost savings of CHF 20,886 (€ 18,724) and CHF 15,382 (€ 13,790) per person compared with "no intervention" and liraglutide 3 mg, respectively. In addition, OPTI program led to 1.133 and 0.734 quality-adjusted life years (QALYs) gained respectively against its comparators. Scenario analyses showed similar outcomes with cost savings and QALYs gained. CONCLUSION OPTI program is a dominant strategy compared to "no intervention" and liraglutide 3 mg as it leads to both cost savings and QALY gain. Therefore, reimbursing the OPTI program for patients with obesity would be cost-effective for Swiss payers.
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Affiliation(s)
- Mark Nuijten
- Health Economics and Valuation, A2M, Amsterdam, the Netherlands
| | - Livia Dainelli
- Global Market Access & Pricing, Nestlé Health Science, Vevey, Switzerland
| | - Bahareh Rasouli
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Moreno Perugini
- Commercial and Medical Affairs, Pharmaceuticals, Nestlé Health Science, Bridgewater, MA, USA
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Siegel KR, Ali MK, Zhou X, Ng BP, Jawanda S, Proia K, Zhang X, Gregg EW, Albright AL, Zhang P. Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008? Diabetes Care 2020; 43:1557-1592. [PMID: 33534729 DOI: 10.2337/dci20-0017] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/03/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.
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Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mohammed K Ali
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,Hubert Department of Global Health and Department of Family and Preventive Medicine, Emory University, Atlanta, GA
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Boon Peng Ng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,College of Nursing and Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL
| | - Shawn Jawanda
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Krista Proia
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xuanping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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McQueen RB, Geno Rasmussen C, Waugh K, Frohnert BI, Steck AK, Yu L, Baxter J, Rewers M. Cost and Cost-effectiveness of Large-scale Screening for Type 1 Diabetes in Colorado. Diabetes Care 2020; 43:1496-1503. [PMID: 32327420 PMCID: PMC7305000 DOI: 10.2337/dc19-2003] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 04/01/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the costs and project the potential lifetime cost-effectiveness of the ongoing Autoimmunity Screening for Kids (ASK) program, a large-scale, presymptomatic type 1 diabetes screening program for children and adolescents in the metropolitan Denver region. RESEARCH DESIGN AND METHODS We report the resource utilization, costs, and effectiveness measures from the ongoing ASK program compared with usual care (i.e., no screening). Additionally, we report a practical screening scenario by including utilization and costs relevant to routine screening in clinical practice. Finally, we project the potential cost-effectiveness of ASK and routine screening by identifying clinical benchmarks (i.e., diabetic ketoacidosis [DKA] events avoided, HbA1c improvements vs. no screening) needed to meet value thresholds of $50,000-$150,000 per quality-adjusted life-year (QALY) gained over a lifetime horizon. RESULTS Cost per case detected was $4,700 for ASK screening and $14,000 for routine screening. To achieve value thresholds of $50,000-$150,000 per QALY gained, screening costs would need to be offset by cost savings through 20% reductions in DKA events at diagnosis in addition to 0.1% (1.1 mmol/mol) improvements in HbA1c over a lifetime compared with no screening for patients who develop type 1 diabetes. Value thresholds were not met from avoiding DKA events alone in either scenario. CONCLUSIONS Presymptomatic type 1 diabetes screening may be cost-effective in areas with a high prevalence of DKA and an infrastructure facilitating screening and monitoring if the benefits of avoiding DKA events and improved HbA1c persist over long-run time horizons. As more data are collected from ASK, the model will be updated with direct evidence on screening effects.
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Affiliation(s)
- R Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cristy Geno Rasmussen
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Kathleen Waugh
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Brigitte I Frohnert
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Liping Yu
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Judith Baxter
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
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Smith AF, Shinkins B, Hall PS, Hulme CT, Messenger MP. Toward a Framework for Outcome-Based Analytical Performance Specifications: A Methodology Review of Indirect Methods for Evaluating the Impact of Measurement Uncertainty on Clinical Outcomes. Clin Chem 2019; 65:1363-1374. [PMID: 31444309 PMCID: PMC7055686 DOI: 10.1373/clinchem.2018.300954] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 06/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND For medical tests that have a central role in clinical decision-making, current guidelines advocate outcome-based analytical performance specifications. Given that empirical (clinical trial-style) analyses are often impractical or unfeasible in this context, the ability to set such specifications is expected to rely on indirect studies to calculate the impact of test measurement uncertainty on downstream clinical, operational, and economic outcomes. Currently, however, a lack of awareness and guidance concerning available alternative indirect methods is limiting the production of outcome-based specifications. Therefore, our aim was to review available indirect methods and present an analytical framework to inform future outcome-based performance goals. CONTENT A methodology review consisting of database searches and extensive citation tracking was conducted to identify studies using indirect methods to incorporate or evaluate the impact of test measurement uncertainty on downstream outcomes (including clinical accuracy, clinical utility, and/or costs). Eighty-two studies were identified, most of which evaluated the impact of imprecision and/or bias on clinical accuracy. A common analytical framework underpinning the various methods was identified, consisting of 3 key steps: (a) calculation of "true" test values; (b) calculation of measured test values (incorporating uncertainty); and (c) calculation of the impact of discrepancies between (a) and (b) on specified outcomes. A summary of the methods adopted is provided, and key considerations are discussed. CONCLUSIONS Various approaches are available for conducting indirect assessments to inform outcome-based performance specifications. This study provides an overview of methods and key considerations to inform future studies and research in this area.
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Affiliation(s)
- Alison F Smith
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK;
- NIHR Leeds In Vitro Diagnostic (IVD) Co-operative, Leeds, UK
| | - Bethany Shinkins
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK
- NIHR Leeds In Vitro Diagnostic (IVD) Co-operative, Leeds, UK
- CanTest Collaborative, UK
| | - Peter S Hall
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Claire T Hulme
- Test Evaluation Group, Academic Unit of Health Economics, University of Leeds, Leeds, UK
- Health Economics Group, University of Exeter, Exeter, UK
| | - Mike P Messenger
- NIHR Leeds In Vitro Diagnostic (IVD) Co-operative, Leeds, UK
- CanTest Collaborative, UK
- Leeds Centre for Personalised Medicine and Health, University of Leeds, Leeds, UK
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Klatman EL, Jenkins AJ, Ahmedani MY, Ogle GD. Blood glucose meters and test strips: global market and challenges to access in low-resource settings. Lancet Diabetes Endocrinol 2019; 7:150-160. [PMID: 30072234 DOI: 10.1016/s2213-8587(18)30074-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/13/2018] [Accepted: 02/20/2018] [Indexed: 12/23/2022]
Abstract
Blood glucose meters and test strips for self-monitoring of blood glucose (SMBG) are often inaccessible to, and infrequently used by, people with diabetes in countries with limited resources for health care. Supplies for measuring blood glucose can also be scarce in health facilities, despite being needed in a myriad of clinical settings at all levels of the health system. Numerous studies and international guidelines emphasise the value of SMBG in diabetes care, particularly in people with type 1 diabetes. In this Review, we assess global access to blood glucose meters and test strips, collating published information on cost, availability, system accuracy, competitive bidding, technological trends, and non-financial barriers. We also provide new information on global market share data and prices, taxes and tariffs, and product availability. Blood glucose meters and test strips should be viewed similarly to essential medicines, with issues of access prioritised by relevant international agencies. Efforts are needed to reduce tariffs and taxes and to create unified global system accuracy requirements and accountable post-marketing evaluations. Preferential pricing arrangements, pooled procurement, and best-purchasing practices could help to lower direct costs. SMBG supplies should also be included in national health insurance schemes. Enhanced diabetes education of health professionals and patients is crucial to ensure effective use of SMBG. Finally, as technology advances for people who can afford new interstitial fluid glucose monitoring systems, blood glucose meters and test strips must remain available and become more affordable in low-resource settings.
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Affiliation(s)
- Emma Louise Klatman
- International Diabetes Federation Life for a Child Program, Sydney, NSW, Australia.
| | | | | | - Graham David Ogle
- International Diabetes Federation Life for a Child Program, Sydney, NSW, Australia; Diabetes NSW and ACT, Sydney, NSW, Australia
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Abstract
Over recent years there has been an explosion in availability of technical devices to support diabetes self-management. But with this technology revolution comes new hurdles. On paper, the available diabetes technologies should mean that the vast majority of people with type 1 diabetes have optimal glycemic control and are using their preferred therapy choices. Yet, it does not appear to be universally the case. In parallel, suboptimal glycemic control remains stubbornly widespread. Barriers to improvement include access to technology, access to expert diabetes health care professionals, and prohibitive insurance costs. Until access can be improved to ensure the technologies are available and usable by those that need them, there are many people with diabetes who are still losing out.
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Affiliation(s)
- Katharine D. Barnard
- Bournemouth University, Bournemouth,
UK
- Katharine D. Barnard, PhD, Bournemouth
University, Royal London House, Christchurch Road, Bournemouth BH1 3LT.
| | - Marc D. Breton
- University of Virginia School of
Medicine, Charlottesville, VA, USA
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11
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McQueen RB, Breton MD, Craig J, Holmes H, Whittington MD, Ott MA, Campbell JD. Economic Value of Improved Accuracy for Self-Monitoring of Blood Glucose Devices for Type 1 and Type 2 Diabetes in England. J Diabetes Sci Technol 2018; 12:992-1001. [PMID: 29681171 PMCID: PMC6134622 DOI: 10.1177/1932296818769098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objective was to model clinical and economic outcomes of self-monitoring blood glucose (SMBG) devices with varying error ranges and strip prices for type 1 and insulin-treated type 2 diabetes patients in England. METHODS We programmed a simulation model that included separate risk and complication estimates by type of diabetes and evidence from in silico modeling validated by the Food and Drug Administration. Changes in SMBG error were associated with changes in hemoglobin A1c (HbA1c) and separately, changes in hypoglycemia. Markov cohort simulation estimated clinical and economic outcomes. A SMBG device with 8.4% error and strip price of £0.30 (exceeding accuracy requirements by International Organization for Standardization [ISO] 15197:2013/EN ISO 15197:2015) was compared to a device with 15% error (accuracy meeting ISO 15197:2013/EN ISO 15197:2015) and price of £0.20. Outcomes were lifetime costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). RESULTS With SMBG errors associated with changes in HbA1c only, the ICER was £3064 per QALY in type 1 diabetes and £264 668 per QALY in insulin-treated type 2 diabetes for an SMBG device with 8.4% versus 15% error. With SMBG errors associated with hypoglycemic events only, the device exceeding accuracy requirements was cost-saving and more effective in insulin-treated type 1 and type 2 diabetes. CONCLUSIONS Investment in devices with higher strip prices but improved accuracy (less error) appears to be an efficient strategy for insulin-treated diabetes patients at high risk of severe hypoglycemia.
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Affiliation(s)
- Robert Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Robert Brett McQueen, PhD, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C238, 12850 E Montview Blvd, Aurora, CO 80045, USA.
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia Health System, Charlottesville, VA, USA
| | | | | | - Melanie D. Whittington
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Jonathan D. Campbell
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Breton MD, Hinzmann R, Campos-Nañez E, Riddle S, Schoemaker M, Schmelzeisen-Redeker G. Analysis of the Accuracy and Performance of a Continuous Glucose Monitoring Sensor Prototype: An In-Silico Study Using the UVA/PADOVA Type 1 Diabetes Simulator. J Diabetes Sci Technol 2017; 11:545-552. [PMID: 28745098 PMCID: PMC5505429 DOI: 10.1177/1932296816680633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Computer simulation has been shown over the past decade to be a powerful tool to study the impact of medical devices characteristics on clinical outcomes. Specifically, in type 1 diabetes (T1D), computer simulation platforms have all but replaced preclinical studies and are commonly used to study the impact of measurement errors on glycemia. METHOD We use complex mathematical models to represent the characteristics of 3 continuous glucose monitoring systems using previously acquired data. Leveraging these models within the framework of the UVa/Padova T1D simulator, we study the impact of CGM errors in 6 simulation scenarios designed to generate a wide variety of glycemic conditions. Assessment of the simulated accuracy of each different CGM systems is performed using mean absolute relative deviation (MARD) and precision absolute relative deviation (PARD). We also quantify the capacity of each system to detect hypoglycemic events. RESULTS The simulated Roche CGM sensor prototype (RCGM) outperformed the 2 alternate systems (CGM-1 & CGM-2) in accuracy (MARD = 8% vs 11.4% vs 18%) and precision (PARD = 6.4% vs 9.4% vs 14.1%). These results held for all studied glucose and rate of change ranges. Moreover, it detected more than 90% of hypoglycemia, with a mean time lag less than 4 minutes (CGM-1: 86%/15 min, CGM-2: 57%/24 min). CONCLUSION The RCGM system model led to strong performances in these simulation studies, with higher accuracy and precision than alternate systems. Its characteristics placed it firmly as a strong candidate for CGM based therapy, and should be confirmed in large clinical studies.
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Affiliation(s)
- Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
- Marc D. Breton, PhD, Center for Diabetes Technology, University of Virginia, PO Box 400888, Charlottesville, VA 22904-0888, USA.
| | | | - Enrique Campos-Nañez
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
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Parkin CG, Homberg A, Hinzmann R. 9th Annual Symposium on Self-Monitoring of Blood Glucose, April 28-30, 2016, Madrid, Spain. Diabetes Technol Ther 2016; 18:727-747. [PMID: 27710038 DOI: 10.1089/dia.2016.0336] [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: 11/13/2022]
Abstract
International experts in the field of diabetes and diabetes technology met in Madrid, Spain, for the 9th Annual Symposium on Self-Monitoring of Blood Glucose. The goal of these meetings is to establish a global network of experts, thus facilitating new collaborations and research projects to improve the lives of people with diabetes. The 2016 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.
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Price DB, Russell R, Mares R, Burden A, Skinner D, Mikkelsen H, Ding C, Brice R, Chavannes NH, Kocks JWH, Stephens JW, Haughney J. Metabolic Effects Associated with ICS in Patients with COPD and Comorbid Type 2 Diabetes: A Historical Matched Cohort Study. PLoS One 2016; 11:e0162903. [PMID: 27658209 PMCID: PMC5033451 DOI: 10.1371/journal.pone.0162903] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/30/2016] [Indexed: 12/24/2022] Open
Abstract
Background Management guidelines for chronic obstructive pulmonary disease (COPD) recommend that inhaled corticosteroids (ICS) are prescribed to patients with the most severe symptoms. However, these guidelines have not been widely implemented by physicians, leading to widespread use of ICS in patients with mild-to-moderate COPD. Of particular concern is the potential risk of worsening diabetic control associated with ICS use. Here we investigate whether ICS therapy in patients with COPD and comorbid type 2 diabetes mellitus (T2DM) has a negative impact on diabetic control, and whether these negative effects are dose-dependent. Methods and Findings This was a historical matched cohort study utilising primary care medical record data from two large UK databases. We selected patients aged ≥40 years with COPD and T2DM, prescribed ICS (n = 1360) or non-ICS therapy (n = 2642) between 2008 and 2012. The primary endpoint was change in HbA1c between the baseline and outcome periods. After 1:1 matching, each cohort consisted of 682 patients. Over the 12–18-month outcome period, patients prescribed ICS had significantly greater increases in HbA1c values compared with those prescribed non-ICS therapies; adjusted difference 0.16% (95% confidence interval [CI]: 0.05–0.27%) in all COPD patients, and 0.25% (95% CI: 0.10–0.40%) in mild-to-moderate COPD patients. Patients in the ICS cohort also had significantly more diabetes-related general practice visits per year and received more frequent glucose strip prescriptions, compared with those prescribed non-ICS therapies. Patients prescribed higher cumulative doses of ICS (>250 mg) had greater odds of increased HbA1c and/or receiving additional antidiabetic medication, and increased odds of being above the Quality and Outcomes Framework (QOF) target for HbA1c levels, compared with those prescribed lower cumulative doses (≤125 mg). Conclusion For patients with COPD and comorbid T2DM, ICS therapy may have a negative impact on diabetes control. Patients prescribed higher cumulative doses of ICS may be at greater risk of diabetes progression. Trial Registration ENCePP ENCEPP/SDPP/6804
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Affiliation(s)
- David B. Price
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
- Observational and Pragmatic Research Institute, Singapore, Singapore
- * E-mail:
| | - Richard Russell
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rafael Mares
- Research in Real Life Ltd, Cambridge, United Kingdom
| | - Anne Burden
- Cambridge Research Support, Cambridge, United Kingdom
| | | | | | - Cherlyn Ding
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Richard Brice
- Whitstable Medical Practice, Whitstable, Canterbury, United Kingdom
| | - Niels H. Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Janwillem W. H. Kocks
- Department of General Practice and GRIAC Research Institute, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeffrey W. Stephens
- Diabetes Research Group, Institute of Life Sciences, Swansea University, Swansea, United Kingdom
| | - John Haughney
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
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