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NICE: England's Clinical Guidelines: Diabetes Management


09 December 2005

NICE: England's Clinical Guidelines: Diabetes Management

Today seemed to be a rather slow news day up to this point (1 PM in New York: 6 PM here in London) so rather then link a piece of International news -- I thought it may be interesting to talk about the National Health Service (NHS) in the United Kingdom, and the UK perspective on pump therapy. At first glance, this may seem to be all about Type 1, and in some ways it is. However, the ADA (American Diabetes Association) mentions on their site that there is an increase of Type 2's using the pump. This is not the case over here in the U.K. nor in Continental Europe, but I would love to hear any feedback on T2 pump users in the States.

Back to the NHS and N.I.C.E Guidelines. NICE stands for the National Institute for Clinical Excellence and every UK GP or Specialist (endocrinologist) working for the NHS must adhere to these guidelines when assessing a patient. The Guidelines for pump therapy, after conducting a study in 2002-2003, concluded that:

The Appraisal Committee considered that the evidence from clinical trials comparing CSII (sub-cutaneous insulin infusion) therapy with MDI (multiple dose insulin) therapy showed that - on the basis of the outcomes measured - either CSII therapy is no more effective than MDI therapy or if CSII is more effective, then at best the difference between the two therapies is small.
The Committee's view was that the proportion of people with type 1 diabetes who would be appropriate for, and would take up, insulin pump therapy, would be of the order of 1-2% of the total. For this small group of people for whom CSII therapy could make a large difference, the following conditions would have to apply for the therapy to be considered cost effective. The diabetes would have to be poorly controlled, as measured by achievement of accepted levels of HbA1c, using MDI therapy (including a sufficiently long use of insulin glargine, where appropriate, to determine its effectiveness. CSII therapy should provide significantly better control than MDI therapy (with the use of insulin glargine, where appropriate) and prevent the occurrence of disabling hypoglycaemic events.
The Committee considered that for this specific group of patients (1%) the increase in utility would be of the order of 0.035 or more. On this basis, at a net cost of £1100 per year to the NHS, CSII would be likely to be cost effective.
(NHS budget would increase by 3.5 million for 1% and 7 million for 2% in sterling).

This means that for 1-2% of the total diabetic population (Type 1's only), the above conditions must be met. Not only that, but consider that poor control is a requirement for assessment! That would seem to make for a very tricky patient review; pregnancy and young children are also put under the same strict guidelines.

For all of you in Los Angeles, New York and anywhere in between -- is healthcare in the US more advanced? I believe it is! Take pity on your poorer cousins here in Europe! And for those of us here in the United Kingdom, let's try to change the current practice! The proposal for review on the Guideline is slated for February 2006. Just over 2 months away.


Blogger Megan said...

That's interesting. Sorry to hear pump therapy is so tough to get over there. I just started reading your blog, but I see from your picture that you are using a pump. May I ask how you were able to get yours?

12:51 AM  
Blogger Elizabeth Snouffer said...

Hi Megan:

I was finally given a pump after the birth of my daughter, not before (which is often the case today.) I was living in New York and my doctor and I both worked hard on getting my (then) Insurance Company to approve the request. I then moved to Rome, Italy and lived there with that pump for about 4 years. Pumps are usually under warranty for four years, and when I moved to the UK, it had timed-out. I worked with my current endo at Guys Hospital here in London to replace the pump both through my own private insurance and the NHS. My doctor had gotten the NHS to more quickly approve the replacement for a wide variety of reasons -- one of which is that I live in a very council rich zone (UK speak - sorry!) and the other is that I was already a pump user so issues regarding compliance and usage were not a hindrance.

For many reasons, the pump is the way to go for many (not all) if you are IDDM - insulin dependent. Look at it this way, how else can you get a 24 hour subcutaneous drip without a transplant. It is really the most effective treatment. It mimics the work of a pancreas. Hope this helps!

3:36 PM  
Blogger Megan said...

Glad to hear you were able to get it. I live in NY now, by the way.

10:50 PM  

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