Use of insulin pumps and closed‐loop systems among people living with diabetes: A narrative review of clinical and cost‐effectiveness to enable access to technology and meet the needs of payers

Abstract

The use of continuous subcutaneous insulin infusion (CSII) via insulin pumps is today considered standard of care for type 1 diabetes (T1D). Closed-loop systems combining continuous glucose monitoring with automated algorithm-driven insulin delivery have been shown to be safe and efficacious in randomized controlled trials and reallife studies in both paediatric and adult participants with T1D. Implementation of hybrid closed-loop (HCL) systems has shown incremental effectiveness, with further reduction of hypoglycaemia and hyperglycaemia. Although less extensively studied in type 2 diabetes (T2D), insulin pumps have demonstrated their effectiveness in glucose control, along with a reduction in need for insulin and a neutral effect on weight.Recent studies have also shown promising results with the use of HCL systems in T2D. Cost-effectiveness studies in both T1D and T2D have shown that pump use is cost-effective in several countries, leading to improvements in quality-adjusted lifeyears. Insulin pumps are currently reimbursed for T1D in many European countries, but in only a few for individuals with T2D. HCL systems are to be evaluated in future trials performed in T2D to compare their incremental efficacy and cost-effectiveness in comparison with available intensification tools which include multiple daily insulin injections, metformin, sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. There is a need for updated guidelines for the use of CSII and HCL in individuals living with T2D based on the emerging evidence, with identification of and recommendations for the people who would benefit the most, which would eventually form a basis for reimbursement and health policies. K E Y W O R D S continuous glucose monitoring (GCM), cost-effectiveness, CSII, insulin pump therapy, type 2 diabetes This article has an accompanied Plain Language Summary in the Supporting Information Data S1.

Beneficial effects of automated insulin delivery over one‐year follow‐up in real life for youths and adults with type 1 diabetes irrespective of patient characteristics

“…It should be mentioned that financial considerations and household incomes were not barriers, as access to technology in France is easy, because of the complete reimbursement of AID systems after evaluation of cost-effectiveness by the payers. 17 Although keys of success with the implementation of automated closed-loop insulin delivery have been clearly defined by a position statement, 18 several factors may mitigate the performance of AID technology. CHO counting is perceived as one of the most burdensome tasks by PwT1D and can explain variability in insulin requirements.…”

Should people with type 2 diabetes treated by multiple daily insulin injections with home health care support be switched to hybrid closed‐loop? The CLOSE AP+ randomized controlled trial

“…There is a large body of evidence showing beneficial effects of insulin pumps and AID systems in individuals living with type 1 diabetes 14,22 . The use of insulin pumps in people with type 2 diabetes is a more recent practice compared with its use in type 1 diabetes 15 . A meta‐analysis, which included the OPT2MISE study and four smaller randomized studies, has shown the superiority of pump therapy compared with MDI, including a reduction in HbA1c, reduction of daily insulin dose and improved weight maintenance 11 .…”

“…Barriers to the use of pumps and AID systems for treating type 2 diabetes include the lack of clinical guidelines to select those patients who will benefit from these technologies, lack of FDA approval and CE labelling according to the American and European regulations for AID indications in type 2 diabetes, the variable HHP resources and the varied funding and reimbursement for medical devices and associated HHC services depending on the country. Studies of cost‐effectiveness are now required to show the possible economic advantages of using an AID system in selected people with type 2 diabetes 15 . The availability of HHC services and their reimbursement by the French social insurance is unique and far from being a widespread convenience among other countries.…”

“…Clinical trials and real‐life studies have shown the feasibility, safety and efficacy of pump therapy in people with type 2 diabetes, despite potential barriers such as older age, 12 comorbidities, 10 or cognitive limitations 13 . AID systems have been developed for treating people with type 1 diabetes and many studies have shown their efficacy in improving glucose control and quality of life, while allowing cost savings for health care insurance systems 14,15 . Data are scarce regarding the use of AID systems in people with type 2 diabetes, as studies are limited to short‐term trials in hospital 16 and out‐of‐hospital settings 17,18 .…”

“…13 AID systems have been developed for treating people with type 1 diabetes and many studies have shown their efficacy in improving glucose control and quality of life, while allowing cost savings for health care insurance systems. 14,15 Data are scarce regarding the use of AID systems in people with type 2 diabetes, as studies are limited to short-term trials in hospital 16 and out-of-hospital settings. 17,18 In out-of-hospital studies, people were taught to manage their medical devices independently after an appropriate training period to handle use of insulin pumps, sensors and AID systems.…”