Colquitt, J. L. (Jill L.), Green, C., Sidhu, M. K., Hartwell, D. (Debbie L.) and Waugh, Norman (2004) Clinical and cost-effectiveness of continuous subcutaneous insulin infusion for diabetes. Health Technology Assessment, Vol.8 (No.43).

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Abstract

Objectives: To assess the clinical and cost-effectiveness
of continuous subcutaneous insulin infusion (CSII)
compared with multiple daily injections (MDI) in the
delivery of intensive insulin therapy for the treatment
of diabetes mellitus.
Data sources: Electronic databases, references of
retrieved articles and manufacturer submissions.
Experts in the field were consulted.
Review methods: For the systematic review of clinical
and cost-effectiveness, studies were assessed for
inclusion according to predefined criteria by two
reviewers. Data extraction and quality assessment
were undertaken by one reviewer and checked by a
second reviewer. Data on clinical effectiveness were
synthesised through a narrative review with full
tabulation of all eligible studies, with meta-analysis
performed where appropriate.
Results: Twenty studies comparing CSII with MDI
were identified. Quality was generally poor. In adults
with Type 1 diabetes, glycated haemoglobin improved
by 0.61% (95% CI –1.29 to 0.07) in longer term
studies, although this improvement was smaller when a
study using bovine ultralente was excluded. A reduction
in insulin dose with CSII of about 12 units per day
(–11.90, 95% CI –18.16 to 5.63) was found in shortterm
studies, with smaller differences in longer term
studies. Body weight and cholesterol levels were
similar between treatments. Hypoglycaemic events did
not differ significantly between CSII and MDI in most
trials, but some found fewer events with CSII and one
found more hypoglycaemia and hypoglycaemic coma
with CSII. There was no consistency between the
studies in patient preference, but progress has been
made both with insulin pumps and injector pens since
the publication of many of the older studies. No
difference in glycated haemoglobin between CSII and
MDI was found in pregnancy; one study found less
insulin was required by patients with CSII, but two
other studies found no significant difference. One study
of adolescents found lower glycated haemoglobin and
insulin dose with CSII whereas a second study found no
significant difference. In CSII analogue insulin was
associated with lower glycated haemoglobin levels than
soluble insulin. No economic evaluations comparing
CSII with MDI were identified. The estimated
additional cost of CSII compared to MDI varies from
£1091 per annum to £1680 per annum, according to
the make of the insulin pump and the estimated life of
the device. These estimates include the costs for the
insulin pump, the consumables associated with delivery
of CSII, and an allowance for the initial education
required when patients switch from MDI to CSII.
The largest component of the annual cost for
CSII is the cost of consumable items (e.g. infusion
sets).
Conclusions: When compared with optimised MDI,
CSII results in a modest but worthwhile improvement
in glycated haemoglobin in adults with Type 1 diabetes.
It has not been possible to establish the longer term
benefits of such a difference in glycated haemoglobin,
although there is an expectation that it would be
reflected in a reduction in long-term complications.
More immediate primary benefits from CSII may be
associated with an impact on the incidence of
hypoglycaemic events and the dawn phenomenon, and
greater flexibility of lifestyle. However, there is limited
evidence on this, and information presented to offer
context on quality-of-life is based on testimonies from
those patients who have had a positive experience of
CSII. The estimated cost to the NHS per year for
CSII would be around £3.5 million in England and
Wales if 1% of people with Type 1 diabetes used CSII,
£10.5 million for 3%, and £17.5 million for 5%.
Further research should focus on wider benefits of
CSII, such as flexibility of lifestyle and quality of life,
and on the psychological impact of wearing a device for
24 hours every day. Research into the use of CSII in
children of different ages is also needed.

Item Type:	Journal Article
Subjects:	R Medicine > RC Internal medicine
Divisions:	Faculty of Medicine > Warwick Medical School > Health Sciences > Population, Evidence & Technologies (PET) > Warwick Evidence Faculty of Medicine > Warwick Medical School > Health Sciences Faculty of Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Diabetes -- Treatment, Insulin -- Therapeutic use -- Administration
Journal or Publication Title:	Health Technology Assessment
Publisher:	NIHR Health Technology Assessment programme
ISSN:	1366-5278
Official Date:	2004
Dates:	Date Event 2004 Published
Volume:	Vol.8
Number:	No.43
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
Funder:	NIHR Health Technology Assessment Programme (Great Britain)

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