Health care costs for Swedish adults with type 1 diabetes who use insulin pump therapy compared with those who use multiple daily injections, in a study published in Diabetes Care

“In principle, optimal glycemic control may be achieved by either [multiple daily injection] or insulin pump therapy,” Katarina Steen CarlssonPhD, of the department of clinical sciences at University in Sweden, and colleagues wrote.

“In practice, where individuals with type 1 diabetes face challenges of the disease in daily management, the two modes of insulin administration could differ in effectiveness, ease of use and association with adverse events, and, therefore, be associated with differences in patient outcomes.”

Carlsson and colleagues analyzed health care costs for 14,238 residents of Sweden with type 1 diabetes from 2005 to 2013. Of the total cohort, 4,991 used insulin pump therapy (mean age, 33.8 years; 51.1% women). Insulin pump therapy users were double-matched to 9,247 adults who used multiple injection therapy (mean age, 33.8 years; 51.3% women).

Data about diabetes diagnosis and insulin treatment regimens were obtained from the Swedish National Diabetes Register. Longitudinal health and socioeconomic data were collected from the National Patient Register, National Prescribed Drug Register, National Cause of Death Register and National Integrated Database for Labor Market Research. 

The researchers found that annual costs for adults who used insulin pump therapywere $3,923 more than those who used multiple daily injections (95% CI, 3,703-4,143). There were also more annual outpatient visits among pump users compared with multiple daily injection users (3.8 vs. 3.5; P < .001).

Pump users had higher average costs for outpatient treatment ($1,665; 95% CI, 1,615-1,714) compared with multiple daily injection users ($1,507; 95% CI, 1,473-1,542). Overall inpatient costs were higher for pump users ($1,972; 95% CI, 1.864-2,081) compared with multiple daily injection users ($1,897; 95% CI, 1,826-1,968), specifically in relation to inpatient services for diabetes complications (P < .012). Pump users also spent more annually on medication costs, including disposables ($5,861; 95% CI, 5,814-5,907), than multiple daily injection users ($2,285; 95% CI, 2,270-2,300). 

Subgroup analysis revealed that health care costs, both for pump therapy and multiple daily injections, were higher for women compared with men (< .001), adults aged at least 48 years compared with younger adults (P < .001) and those with diabetes duration of 20 years or more compared with shorter duration (P < .001). In addition, higher HbA1c levels at enrollment in the Swedish National Diabetes Register were associated with increased costs (P <.001), as was starting therapy at age 18 years or older compared with younger (P < .001). 

“Whether insulin pump therapy is cost-efficient, ultimately, depends on therapeutic effects beyond resource use and costs as well as on how much the payer is prepared to invest in additional quality-adjusted life-years,” the researchers wrote. “Identification of tangible and intangible patient benefits from insulin pump therapy over time remain important to the valuation of technology and support of resource allocation decisions.”

Real-World Costs of Continuous Insulin Pump Therapy and Multiple Daily Injections for Type 1 Diabetes: A Population-Based and Propensity-Matched Cohort From the Swedish National Diabetes Register.

Emilie Toresson Grip, Ann-Marie Svensson, Mervete Miftaraj, Björn Eliasson, Stefan Franzén, Soffia Gudbjörnsdottir and Katarina Steen Carlsson

Diabetes Care 2019 Jan; dc181850. https://doi.org/10.2337/dc18-1850

Abstract

OBJECTIVE To investigate real-world costs of continuous insulin pump therapy compared with multiple daily injection (MDI) therapy for type 1 diabetes.

RESEARCH DESIGN AND METHODS Individuals with type 1 diabetes and pump therapy in the Swedish National Diabetes Register (NDR) since 2002 were eligible. Control subjects on MDI were matched 2:1 using time-varying propensity scores. Longitudinal data on health care resource use, antidiabetic treatment, sickness absence, and early retirement were taken from national registers for 2005–2013. Mean annual costs were analyzed using univariate analysis. Regression analyses explored the role of sociodemographic factors. Subgroup and sensitivity analyses were performed.

RESULTS A total of 14,238 individuals with type 1 diabetes entered in the NDR between 2005 and 2013 (insulin pump n = 4,991, MDI n = 9,247, with switches allowed during the study) were included. Mean age at baseline was 34 years, with 21 years of diabetes duration and a mean HbA1c of 8.1% (65 mmol/mol). We had 73,920 person-years of observation with a mean follow-up of 5 years per participant. Mean annual costs were higher for pump therapy than for MDI therapy ($12,928 vs. $9,005, respectively; P < 0.001; mean difference $3,923 [95% CI $3,703–$4,143]). Health care costs, including medications and disposables, accounted for 73% of the costs for pump therapy and 63% of the costs for MDI therapy. Regression analyses showed higher costs for low education, low disposable income, women, and older age.

CONCLUSIONS Nine years of real-world data on all measurable diabetes-related resource use show robust results for additional costs of insulin pump therapy in adults by subgroup and alternative propensity score specifications. Identification of tangible and intangible benefits of pump therapy over time remain important to support resource allocation decisions.

 

See also

Insulin pump reduces mortality from cardiovascular disease by almost 50%

 

People with type 1 diabetes who use insulin pump therapy face almost 50% less risk of dying from cardiovascular disease than those who take insulin by multiple daily injections. The British Medical Journal has published a study conducted at Sahlgrenska Academy.

Based on the National Diabetes Register, researchers monitored 18,168 Swedes with type 1 diabetes from 2005 to 2012. While 2,441 of the subjects used insulin pump therapy, the others relied on multiple daily injections.

Lower risk

The study found that insulin pump users had a substantially lower risk of dying of cardiovascular disease than the daily injection group. The correlation was statistically certain.

"We carefully analyzed the findings to eliminate the risk of bias or confounding and concluded that the effect had been fully verified," says Isabelle Steineck, researcher at Sahlgrenska Academy.

More frequent monitoring

The next step will be to identify the mechanisms that explain the extra benefits of insulin pump therapy. Dr. Steineck believes that one reason for the difference between the two therapies is that the insulin pump method is accompanied by more extensive patient training and more frequent blood glucose monitoring.

”There is a rationale for insulin pump treatment resulting in more stable blood glucose concentrations than multiple daily injections” she says. ”Previous studies have shown that insulin pump can reduce the frequencies of severe hypoglycemic episodes. Severe hypoglycaemia can be a risk factor for cardiovascular events, particularly among high risk individuals.”

”We evaluated the patients who used insulin pump therapy and do not know if the observed effect is attributable to continuous infusion of insulin or that some of the effect is attributable to intensified glucose monitoring, increased motivation to control blood glucose, or a better knowledge about having diabetes type 1”says Isabelle Steineck.

Safe and effective

The researchers have concluded that insulin pumps not only make life easier for patients, but represent a safe and effective treatment method.

"This is good news for anyone with type 1 diabetes," says Soffia Gudbjörnsdottir, diabetologist and director of the Swedish National Diabetes Register. "But not everybody wants to use a pump, and the biggest priority is still to optimize blood glucose monitoring."

Approximately 20% of Swedish type 1 diabetes patients have access to insulin pump therapy. But earlier studies at Sahlgrenska Academy have demonstrated that hospitals vary greatly – anywhere from 12% to almost 30% of patients may receive pumps.

The article “Insulin Pump Therapy, Multiple Daily Injections and Cardiovascular Mortality in 18,168 People with Type 1 Diabetes: Observational Study” was published online by the British Medical Journal on June 22.

Link to article

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