使用连续血糖监测的 T1D 成人起始胰岛素泵与多次胰岛素注射相比的成本效益：DIAMOND 随机试验。
Cost-effectiveness of Initiating an Insulin Pump in T1D Adults Using Continuous Glucose Monitoring Compared with Multiple Daily Insulin Injections: The DIAMOND Randomized Trial.
机构信息
Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).
School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).
出版信息
Med Decis Making. 2018 Nov;38(8):942-953. doi: 10.1177/0272989X18803109.
BACKGROUND
The economic impact of both continuous glucose monitoring (CGM) and insulin pumps (continuous subcutaneous insulin infusion [CSII]) in type 1 diabetes (T1D) have been evaluated separately. However, the cost-effectiveness of adding CSII to existing CGM users has not yet been assessed.
OBJECTIVE
The aim of this study was to evaluate the societal cost-effectiveness of CSII versus continuing multiple daily injections (MDI) in adults with T1D already using CGM.
METHODS
In the second phase of the DIAMOND trial, 75 adults using CGM were randomized to either CGM+CSII or CGM+MDI (control) and surveyed at baseline and 28 weeks. We performed within-trial and lifetime cost-effectiveness analyses (CEAs) and estimated lifetime costs and quality-adjusted life-years (QALYs) via a modified Sheffield T1D model.
RESULTS
Within the trial, the CGM+CSII group had a significant reduction in quality of life from baseline (-0.02 ± 0.05 difference in difference [DiD]) compared with controls. Total per-person 28-week costs were $8,272 (CGM+CSII) versus $5,623 (CGM+MDI); the difference in costs was primarily attributable to pump use ($2,644). Pump users reduced insulin intake (-12.8 units DiD) but increased the use of daily number of test strips (+1.2 DiD). Pump users also increased time with glucose in range of 70 to 180 mg/dL but had a higher HbA1c (+0.13 DiD) and more nonsevere hypoglycemic events. In the lifetime CEA, CGM+CSII would increase total costs by $112,045 DiD, decrease QALYs by 0.71, and decrease life expectancy by 0.48 years.
CONCLUSIONS
Based on this single trial, initiating an insulin pump in adults with T1D already using CGM was associated with higher costs and reduced quality of life. Additional evidence regarding the clinical effects of adopting combinations of new technologies from trials and real-world populations is needed to confirm these findings.
背景
连续血糖监测（CGM）和胰岛素泵（连续皮下胰岛素输注[CSII]）在 1 型糖尿病（T1D）中的经济影响已分别进行了评估。然而，尚未评估在使用 CGM 的 T1D 患者中添加 CSII 的成本效益。
目的
本研究旨在评估在已经使用 CGM 的 T1D 成人中，CSII 相较于继续使用多次每日注射（MDI）的成本效益。
方法
在 DIAMOND 试验的第二阶段，75 名使用 CGM 的成年人被随机分配到 CGM+CSII 或 CGM+MDI（对照组），并在基线和 28 周时进行了调查。我们进行了试验内和终身成本效益分析（CEA），并通过改良的谢菲尔德 T1D 模型估算了终身成本和质量调整生命年（QALY）。
结果
在试验内，CGM+CSII 组的生活质量从基线开始有显著下降（差异为 -0.02 ± 0.05），与对照组相比。28 周时，每人的总费用分别为 8272 美元（CGM+CSII）和 5623 美元（CGM+MDI）；费用差异主要归因于泵的使用（2644 美元）。泵使用者减少了胰岛素用量（-12.8 单位差异），但增加了每日测试条的使用次数（+1.2 差异）。泵使用者还增加了血糖在 70 至 180mg/dL 范围内的时间，但 HbA1c 升高（+0.13 差异），非严重低血糖事件更多。在终身 CEA 中，CGM+CSII 会增加 112045 美元的总成本，减少 0.71 个 QALY，并减少 0.48 年的预期寿命。
结论
基于这一项单中心试验，在已经使用 CGM 的 T1D 成人中启动胰岛素泵会导致更高的成本和更低的生活质量。需要来自临床试验和真实世界人群的新组合技术的临床效果的更多证据来证实这些发现。
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