NZSSD Position Statement on Insulin Pump Therapy

NZSSD welcomes the "Systematic Review Update and Economic Evaluation for the New Zealand Setting on Subcutaneous Insulin Pump Therapy." The major conclusions of this study are that the improvement in glycaemic control is of "small magnitude and of borderline statistical significance". This is regardless of the patient population studied (adults, children, adolescents, Type 1 or Type 2 diabetes). The report estimates that the cost/QALY is likely to exceed $100,000.

In response to this systematic review, NZSSD believes that certain patient populations are more likely to derive clinical benefit from insulin pump therapy than others, for example, those with Type 1 diabetes who experience recurrent severe hypoglycaemia despite multiple daily injections (MDI). Studies of insulin pump therapy v MDI have not addressed this particular patient population specifically.

The National Institute for Health and Clinical Excellence (NICE) [1] in the UK have recently re-appraised the use of insulin pump therapy and have concluded that they constitute an appropriate treatment option for adults and children 12 years and older with type 1 diabetes mellitus provided that:

  • Attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections result in the person experiencing disabling hypoglycaemia. For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life
  • HbA1c levels have remained high (that is, at 8.5% or above) on MDI therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care.
  • CSII therapy is recommended as a treatment option for children younger than 12 years with type 1 diabetes mellitus provided that:
    • MDI therapy is considered to be impractical or inappropriate, and
    • Children on insulin pumps would be expected to undergo a trial of MDI therapy between the ages of 12 and 18 years.

Insulin pump therapy is currently funded on a population based formula, essentially resulting in each district health board (DHB) receiving a fixed amount of annual funding for insulin pump therapy. Given this scenario an individual DHB can only fund a fixed number of people on insulin pumps (assuming that funding pays for the pump and consumables), since after several years all of the funding is required for funding the consumables of those established on pump therapy.

This creates a "first come first served" situation which is not equitable. Individual DHB's have attempted to address this issue in a variety of ways (e.g. some choosing to only fund pumps and not consumables, others acquiring pumps through other funding streams). This has resulted in significant variability of insulin pump services in different regions throughout New Zealand.

The NZSSD Executive believes that Insulin Pump Therapy should be available:

  • To people with Type 1 diabetes who, despite optimal high level care and MDI using a long acting analogue, meet the following criteria:
    • Recurrent severe [2] unexplained hypoglycaemic episodes (2 or more in a 12 month period).
    • Women who have suboptimal glycaemic control and wanting to conceive.
    • Children (<12 years) in whom MDI is judged to be impractical.
    • Poor glycaemic control (HbA1c >8.5%) demonstrated by CGM to be due to a prominent dawn phenomenon
    • Other selected situations: gastroparesis, eating disorders.
  • The person should be assessed by a physician experienced in insulin pump therapy, and would include evidence of adherence to appropriate nutritional and self-monitoring practices.
  • Pump therapy should be administered through the special authority mechanism or equivalent criteria-based methodology. A national panel should be developed to assess applications.
  • Pump therapy should only be commenced and supervised by a diabetes service that has the appropriate experience and resources to manage insulin pump therapy.
  • Access to treatment should be consistent throughout New Zealand.
  • Funding should apply to the pump and consumables.
  • Response to treatment (according to pre-defined outcomes) should be demonstrated annually to be eligible for on-going funding.

NZSSD, June 2008

 

  1. National Institute For Health And Clinical Excellence, Final appraisal determination. Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (review of technology appraisal guidance 57):
    http://www.nice.org.uk/nicemedia/pdf/FinalAppraisalDeterminationIP.pdf at 31 May 2008
  2. Severe defined as disabling hypoglycaemia requiring administration of glucagon or intervention by medical personnel.

Original report

Campbell S, Suebwongpat A, Standfield L, Weston A. Systematic review update and economic evaluation for the New Zealand setting: Subcutaneous insulin pump therapy. HSAC Report 2008; 1(3). Available online at:
http://www.hsci.canterbury.ac.nz/documents/Subcutaneous_Insulin_Pump.pdf