Cost-effectiveness of sensor-augmented insulin pump therapy vs continuous subcutaneous insulin infusion in patients with type 1 diabetes in the Netherlands

Figures & data

Table 1 Baseline cohort characteristics

	Mean (SD)
Cohort with suboptimal glycemic control at baseline^Citation17,Citation18
Age, years	27 (15.6)
Male, %	48.5
Duration of diabetes, years	13.2 (10.8)
HbA1c, % (mmol/mol)	8.0 (64)
Cohort with increased risk of hypoglycemic events^Citation19
Age, years	18.6 (11.8)
Male, %	49.5
Duration of diabetes, years	11 (8.9)
HbA1c, % (mmol/mol)	7.5 (58)

Table 2 Costs of diabetes-related complications

Complication	Cost, EUR	References
Myocardial infarction, year of event	5,138	^Citation21
Myocardial infarction, subsequent years	1,932	^Citation21
Angina, first year	11,119	^Citation22
Angina, subsequent years	154	^Citation23, ^Citation24
Congestive heart failure, first year	2,870	^Citation25
Congestive heart failure, subsequent years	325	^Citation23, ^Citation24, ^Citation25
Stroke, year of event	13,819	^Citation21
Stroke, subsequent years	1,932	^Citation21
Stroke death within 30 days	8,603	^Citation21, ^Citation25
Hemodialysis, annual	89,447	^Citation26
Peritoneal dialysis, annual	66,434	^Citation26
Renal transplant, first year	91,503	^Citation25
Renal transplant, subsequent years	3,680	^Citation25
Severe hypoglycemic event	2,567	^Citation25
Minor hypoglycemic event	0	Assumed
Ketoacidosis event	4,468	^Citation25
Lactic acidosis event	4,468	^Citation25
Edema onset	5,651	^Citation25
Edema follow-up	711	^Citation25
Laser photocoagulation	543	^Citation25
Cataract operation	2,955	^Citation25
Cataract operation follow-up	204	^Citation25
Blindness, year of onset	919	^Citation25
Blindness, subsequent years	441	^Citation25
Neuropathy, year of onset	10,335	^Citation25
Neuropathy, subsequent years	528	^Citation25
Amputation event	59,111	^Citation25
Amputation prosthesis	4,000	^Citation27
Gangrene treatment	1,250	^Citation28
After healed ulcer	154	^Citation28
Infected ulcer	1,690	^Citation28
Standard uninfected ulcer	2,678	^Citation28
Healed ulcer, history of amputation	1,608	^Citation28

Note: All costs are presented in 2014 EUR.

Table 3 Summary of base case analyses

	SAP	CSII	Δ SAP−CSII
Hyperglycemia at baseline cohort
Quality-adjusted life expectancy, QALYs	15.54	13.77	1.77
Total costs, EUR	189,855	150,366	39,489
Total direct costs, EUR	119,799	75,301	44,498
Treatment costs	61,927	14,989	46,938
Management costs	19,461	19,150	311
Cardiovascular complication costs	4,355	4,332	23
Renal complication costs	11,665	13,351	−1,686
Ulcer/amputation/neuropathy costs	16,912	18,008	−1,096
Ophthalmic complication costs	3,211	3,212	−1
ICER, EUR per QALY gained	22,325
Increased risk for hypoglycemia cohort
Quality-adjusted life expectancy, QALYs	16.70	14.53	2.16
Total costs, EUR	204,013	171,032	32,981
Total direct costs, EUR	125,021	86,676	38,345
Treatment costs	66,246	16,144	50,102
Management costs	20,829	20,658	171
Cardiovascular complication costs	3,495	3,432	63
Renal complication costs	11,104	10,963	141
Ulcer/amputation/neuropathy costs	18,419	18,187	232
Ophthalmic complication costs	3,689	3,638	51
ICER, EUR per QALY gained	15,243

Abbreviations: CSII, continuous subcutaneous insulin infusion; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year; SAP, sensor-augmented pump therapy.

Figure 1 Cost-effectiveness acceptability curve for SAP vs CSII.

Notes: (A) Patients with suboptimal glycemic control at baseline. (B) Patients at increased risk of hypoglycemic events.

Abbreviations: CSII, continuous subcutaneous insulin infusion; QALY, quality-adjusted life year; SAP, sensor-augmented pump therapy.

Table 4 Summary of sensitivity analyses

	Quality-adjusted life expectancy, QALYs			Costs, EUR			ICER, EUR per QALY
	SAP	CSII	Δ	SAP	CSII	Δ
Hyperglycemia at baseline cohory
Base case	15.54	13.77	1.77	189,855	150,366	39,489	22,335
Direct costs only	15.54	13.77	1.77	119,799	75,301	44,498	25,168
Sensor + kit cost, −20%	15.54	13.77	1.77	179,622	150,366	29,256	16,548
Sensor + kit cost, −10%	15.54	13.77	1.77	184,739	150,366	34,373	19,441
Sensor + kit cost, +10%	15.54	13.77	1.77	194,971	150,366	44,635	25,229
Baseline HbA1c, 7.5% (58 mmol/mol)	15.97	14.25	1.72	183,368	141,704	41,664	24,182
Baseline HbA1c, 8.5% (69 mmol/mol)	15.12	13.27	1.85	196,300	160,027	36,273	19,595
Baseline HbA1c, 9.0% (75 mmol/mol)	14.67	12.79	1.88	203,650	169,980	33,670	17,894
Complication costs, +20%	15.54	13.77	1.77	201,402	162,402	39,000	22,059
Complication costs, −20%	15.54	13.77	1.77	178,286	138,310	39,976	22,611
FoH utility =0	14.17	13.77	0.40	189,855	150,366	39,489	98,820
FoH utility =0.0184	14.63	13.77	0.86	189,855	150,366	39,489	46,147
SAP SMBG use =7.11/day	15.54	13.77	1.77	195,757	150,366	45,391	25,673
SAP SMBG use =6.11/day	15.54	13.77	1.77	193,618	150,366	43,252	24,464
SAP SMBG use =2.11/day	15.54	13.77	1.77	185,064	150,366	34,698	19,626
Time horizon, 5 years	3.47	3.20	0.27	25,623	14,029	11,594	42,987
Time horizon, 10 years	6.34	5.81	0.53	51,052	30,713	20,339	38,369
Time horizon, 20 years	10.72	9.72	1.0	101,787	70,575	31,212	31,194
Time horizon, 40 years	14.85	13.24	1.61	173,282	135,259	38,023	23,561
0% discount rate	20.05	17.62	2.43	492,418	418,435	73,893	30,444
1.5% discount rate	15.54	13.77	1.77	331,250	274,672	56,578	32,001
4% discount rate	10.95	9.81	1.14	189,855	150,366	39,489	34,539
Sensor use =48 per year	15.66	13.77	1.89	193,080	150,366	42,714	22,594
Sensor use =61 per year	15.97	13.77	2.26	201,502	150,366	51,136	23,305
Increased risk for hypoglycemic event cohort
Base case	16.79	14.53	2.16	204,013	171,032	32,981	15,243
Direct costs	16.70	14.53	2.16	125,021	86,676	38,345	17,722
0% discount rate	22.03	19.07	2.96	598,386	529,777	68,609	23,186
1.5% discount rate	16.70	14.53	2.16	382,297	332,202	50,095	23,152
4% discount rate	11.45	10.04	1.42	204,013	171,032	32,981	23,298
Time horizon, 10 years	6.28	5.59	0.69	47,493	32,490	15,003	21,756
Time horizon, 20 years	10.84	9.57	2.27	94,631	70,719	23,912	18,870
CSII SHE rate =1 per 100 patient-months	16.70	14.53	2.16	204,013	164,490	39,523	18,288
CSII SHE rate =8 per 100 patient-months	16.70	14.54	2.16	204,013	192,202	11,811	5,470

Abbreviations: CSII, continuous subcutaneous insulin infusion; FoH, fear of hypoglycemia; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year; SAP, sensor-augmented pump therapy; SHE, severe hypoglycemic event; SMBG, self-monitoring of blood glucose.

PickupJCFreemanSCSuttonAJGlycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient dataBMJ2011343d380521737469

 PubMed Web of Science ®Google Scholar

NathanDMClearyPABacklundJYIntensive diabetes treatment and cardiovascular disease in patients with type 1 diabetesN Engl J Med2005353252643265316371630

 PubMed Web of Science ®Google Scholar

LyTTNicholasJARetterathALimEMDavisEAJonesTWEffect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: a randomized clinical trialJAMA2013310121240124724065010

 PubMed Web of Science ®Google Scholar

de VriesFMDenigPVisserSTHakEPostmaMJCost-effectiveness of statins for primary prevention in patients newly diagnosed with type 2 diabetes in the NetherlandsValue Health201417222323024636380

 PubMedGoogle Scholar

EeftingFNathoeHvan DijkDRandomized comparison between stenting and off-pump bypass surgery in patients referred for angioplastyCirculation2003108232870287614656913

 PubMedGoogle Scholar

Nederlands Huisarten Genootschap [homepage on the Internet] Available from: https://www.nhg.orgAccessed May 20, 2017

 Google Scholar

Medicijnkosten.nl [homepage on the Internet] Available from: https://www.medicijnkosten.nl/Accessed May 20, 2017

 Google Scholar

Nederlandse Zorgautoriteit [homepage on the Internet] Available from: https://www.nza.nl/regelgeving/tarieven/Accessed May 20, 2017

 Google Scholar

AdarkwahCCGandjourAAkkermanMEversSMCost-effectiveness of angiotensin-converting enzyme inhibitors for the prevention of diabetic nephropathy in The Netherlands – a Markov modelPLoS One2011610e2613922022539

 PubMedGoogle Scholar

Cz.nl Available from: http://www.cz.nl/~/media/actueel/voorwaarden/bijlagen-bij-basisverzekeringen/hulpmiddelen%20reglement.pdfAccessed March 11, 2014

 Google Scholar

RedekopWKStolkEAKokELovasKKaloZBusschbachJJDiabetic foot ulcers and amputations: estimates of health utility for use in cost-effectiveness analyses of new treatmentsDiabetes Metab200430654955615671925

 PubMed Web of Science ®Google Scholar