Continuous Subcutaneous Insulin Infusion versus Multiple Daily Injections of Insulin
- 199 Downloads
Background: Recent meta-analyses in the published medical literature have found improved glycaemic control with continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) of insulin for patients with diabetes mellitus. In Australia, CSII is predominantly used in type 1 diabetes mellitus (T1DM) patient populations.
Objective/intervention: To project long-term costs and outcomes of CSII (Novorapid® or Humalog®) compared with MDI (NPH insulin plus Novorapid® or Humalog®) in adult and adolescent T1DM patients in Australia.
Methods: The study was a modelling analysis utilising a lifetime horizon in adult and adolescent specialty care T1DM patient populations from Australia. Published Australian diabetes complication costs (adjusted to Australian dollars [$A], year 2006 values), treatment costs and discount rates of 5.0% per annum were applied to costs and clinical outcomes. A lifetime horizon was taken, considering only direct medical costs and excluding indirect and non-medical costs.
The validated CORE diabetes model employs standard Markov/Monte Carlo simulation techniques. It was used to simulate diabetes progression in Australian adult (mean age 43 years, duration of diabetes 17 years, mean glycosylated haemoglobin [HbA1c] 8.2%) and adolescent (mean age 17 years, duration of diabetes 6 years, mean HbA1c 8.9%) patients with baseline characteristics taken predominantly from Australian National Diabetes Information Audit and Benchmarking (ANDIAB) in Australia.
The main outcome measures were incremental costs and effectiveness of CSII compared with MDI in Australian adult and adolescent patients with T1DM.
Results: Mean direct lifetime costs were $A34 642 higher with CSII treatment than with MDI for adult patients and $A41 779 higher for adolescent patients. Treatment with CSII was associated with an improvement in life expectancy of 0.393 years for adults compared with MDI and 0.537 years for adolescents. The corresponding gains in QALYs were 0.467 QALYs and 0.560 QALYs for adults and adolescents, respectively. This produced incremental cost effectiveness ratios (ICERs) of $A88 220 and $A77 851 per life-year gained for CSII compared with MDI for adult and adolescent T1DM patients, respectively, in Australia. These data also produced corresponding ICERs of $A74 147 per QALY and $A74 661/QALY for adult and adolescent T1DM patients, respectively. Sensitivity analyses suggested that our base-case assumptions were mostly robust with improvements in ICERs for reduction in hypoglycaemic events with CSII treatment and worse ICERs for lower HbA1c changes associated with CSII treatment compared with MDI.
Conclusions: Our analysis suggests that CSII is associated with ICERs in the range of $A53 022–259 646 per QALY gained, with most ICERs representing good value for money in Australia under the majority of scenarios explored.
KeywordsInsulin Glargine Insulin Detemir Continuous Subcutaneous Insulin Infusion Multiple Daily Injection Insulin Pump Therapy
This study was supported by an unrestricted grant from Medtronic Australasia to IMS Health. The authors would like to thank Medtronic-Australasia for providing the funding for this project. Medtronic-Australasia did not have a role in directing the outcome of this modelling analysis, but provided information used in the manuscript.
Lyn-Sharon Nash is an employee of Medtronic Australasia and holds stock options. At the time of the analysis, Katrina Zakrzewska was an employee of Medtronic EU, Tolochenaz and Andrew Palmer was an employee of IMS Health. Neale Cohen has received consultancy fees from Medtronic Austalasia.
- 2.Juvenile Diabetes Research Foundation, Australia. Diabetes statistics [online]. Available from URL: http:/Avwwjdrf.org.au/publications/factsheets/diabetes_statistics.html [Accessed 2006 Nov 1]Google Scholar
- 5.Palmer AJ, Roze S, Valentine WJ, et al. The CORE diabetes model: projecting long term clinical outcomes, costs and cost-effectiveness of interventions in diabetes mellitus (types 1 and 2) to support clinical and reimbursement decision making. Curr Med Res Opin 2004; 20 Suppl. 1: S5–S26PubMedCrossRefGoogle Scholar
- 10.National Association of Diabetes Centres. Australian National Diabetes Information Audit and Benchmarking (ANDIAB). Weston: National Association of Diabetes Centres, 2004Google Scholar
- 15.Linkeschova R, Raoul M, Bott U, et al. Less severe hypoglycaemia, better metabolic control, and improved quality of life in type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy: an observational study of 100 consecutive patients followed for a mean of 2 years. Diabetic Med 2002; 19 (9): 746–751PubMedCrossRefGoogle Scholar
- 19.Reserve B ank of Australia. Reserve B ank of Australia: inflation calculator [online]. Available from URL: http://www.rba.gov.au/calculator/calc.go [Accessed 2006 Nov 1]Google Scholar
- 22.Australian Government, Department of Health and Ageing. Australian refined diagnosis related groups (AR-DRG). Canberra: Department of Health and Ageing, 1998Google Scholar
- 23.Data on file. IMS Health, Inc. IMS MAT data for Australia, 2005 Jul 1Google Scholar
- 24.Australian Government, Department of Health and Ageing. Prostheses list. 2005 Aug 1 [online]. Available from URL: http://www.health.gov.au/internet/wcms/publishing.nsf/Contentyhealth-privatehealth-prostheseslist.htm [Accessed 2006 Nov 1]Google Scholar
- 25.Colquitt JL, Green C, Sidhu MK, et al. Clinical and cost-effectiveness of continuous subcutaneous infusions for diabetes [report no. 8 (43)]. Tunbridge Wells, Kent: Gray Publishing, 2004Google Scholar
- 26.Australian Government, National Health and Medical Research Council. Clinical practice guidelines: type 1 diabetes in children and adolescents. 2005 Mar 9 [online]. Available from URL: http://www.nhmrc.gov.au/publications [Accessed 2006 Nov 1]Google Scholar
- 27.Australian Government, Department of Health and Ageing. Pharmaceutical benefits schedule. 2005 Nov 1 [online]. Available from URL: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Pharmaceutical±Benefits+Scheme+ (PBS)-l [Accessed 2006 Nov 1]Google Scholar
- 28.Chemist Australia. Chemist Australia [online]. Available from URL: http://www.chemistaustralia.com.au/contact.jspc [Accessed 2006 Nov 1]Google Scholar
- 29.Marion L. Setting up a community based pump service. Australian Diabetes Society & Australian Diabetes Educators Association Annual Scientific Meeting; 2005 Sep 7–9; Perth [online]. Available from URL: http://www.racp.edu.au/ads/ [Accessed 2006 Nov 1]Google Scholar
- 30.Australian Government, Department of Health and Ageing. Medicare benefits schedule. 2005 Nov [online]. Available from URL: http://www9.health.gov.au/rribs/ [Accessed 2006 Nov 1]Google Scholar
- 31.Australian Government, Department of Health and Ageing. Remake of paragraph (bj) and 2005-2006 increases in basic default table of health insurance for hospitals and day hospital facilities. Private Health Insurance (PHI) circular 33/05; 2005 Jun 30. Available from URL: http://www.health.gov.au [Accessed 2006 Nov 1]Google Scholar
- 32.Australian Institute of Health and Welfare. The burden of disease and injury in Australia. Canberra: Australian Government, 2003Google Scholar
- 33.National Institute for Clinical Excellence (NICE). Guidance on the use of long-acting insulin analogues for the treatment of diabetes: insulin glargine [online]. Available from URL: http://guidance.nice.org.uk/TA53/publicinfo/pdf/English [Accessed 2007 Aug 30]Google Scholar
- 35.Clarke P, Gray A, Holman R. Estimating utility values for health states of type 2 diabetic patients using the EQ-5D (UKPDS 62). Med Dec Mak 2002; 22 (4): 340–349Google Scholar
- 37.Commonwealth Department of Health and Ageing. Guidelines for the pharmaceutical industry on preparation of submissions to the Pharmaceutical Benefits Advisory Committee. Canberra: Commonwealth of Australia, Publications Production Unit, 2002 SepGoogle Scholar
- 45.National Institute for Clinical Excellence (NICE). Guide to the technology appraisal process [report no. N0014]. London: National Institute for Clinical Excellence, 2001 JunGoogle Scholar
- 46.Juvenile Diabetes Research Foundation, Australia. The incidence, prevalence, and impact of hypoglycaemic events in people with type 1 diabetes. 2006 February: 1–6 [online]. Available from URL: http://www.jdrf.org.au/living_w_diabe-tes/news/JDRF_hypoglycaemia_survey_finding-s_FINALv3.pdf [Accessed 2006 Nov 1]Google Scholar