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Ten ways to enhance a diabetes pathway

Map of Medicine, having systematically analysed the evidence on diabetes care, provides a snapshot of ways to reduce costs without compromising quality.

1) Make the dose adjustment for normal eating (DAFNE) structured patient education programme available to all type 1 patients at initial diagnosis.1

The relatively modest cost of educational programmes means only small improvements are needed to make them cost-effective. Furthermore these programmes reduce the number of acute admissions for complications of diabetes.The DAFNE educational programme is associated with a net cost saving, over 10 years, of £2,679 per patient and a higher number of quality-adjusted life years.1 For type 2 patients, the DESMOND education programme should be made available on initial diagnosis.2

2) Discourage routine self-monitoring of blood glucose for non-insulin-treated people with type 2 diabetes.3

A 2009 National Institute for Health Research health technology assessment (HTA) concluded there was no convincing evidence to support routine self-monitoring in people with type 2 diabetes, except for patients in the following groups: those on maximal oral agents approaching insulin treatment; lean people with abrupt-onset type 2 disease; patients on sulphonylureas with Class 2 driving licences.3 The prescribing of blood glucose testing strips has risen by 11% to 1.4 million items per quarter, and spending has risen 13% to £35.2m over the past five years.4

3) Use metformin as the first-line therapy in all overweight people with type 2 diabetes.5

Modelling by NICE has demonstrated that metformin is the most clinically and cost-effective first-line agent for overweight people with type 2 diabetes compared with other treatments.5

4) Use a sulphonylurea as the first-choice, second-line agent when considering combination therapy for people with type 2 diabetes already on metformin.5

Modelling by NICE has shown that the combination of metformin plus sulphonylurea is more effective and less expensive than metformin plus a rosiglitazone.5

5) Use insulin lispro instead of soluble human insulin as the first-line agent in people with type 1 diabetes.6

An evaluation published in 2009 and assessed by the Centre for Reviews and Dissemination7 found that mealtime insulin lispro improved benefits and reduced costs compared with mealtime soluble human insulin in people with type 1 diabetes.

The lifetime QALYs were 7.601 with insulin lispro and 7.497 with soluble human insulin, while total lifetime costs were £70,576 with insulin lispro and £72,529 with soluble human insulin.

NICE 2004 guidelines on type 1 diabetes in adults recommended soluble human insulin as optimum mealtime insulin therapy,8 but recent evidence from clinical trials has shown the superior profile of rapid or short-acting insulin analogues, such as inslulin lispro, in comparison with conventional soluble human insulin.6

6) Consider continuous subcutaneous insulin infusion (CSII) therapy for adults and children with type 1 diabetes.9

An HTA published in 2010 examining CSII therapy for diabetes reported that offers better blood glucose control, fewer hypoglycaemic episodes, a reduction in the number of insulin doses per day and improved quality of life in people with type 1 diabetes compared with people on analogue-based multiple daily injection (MDI) therapy.9

A 2008 NICE appraisal on the use of CSII therapy recommended that it be used in adults and children over 12 with type 1 diabetes who demonstrated disabling hypoglycaemia or high HbA1C levels (8.5 or above) despite being on MDI therapy.10

Even at an average cost of £1700 per patient, per year compared with MDI regimes, the new technology was still deemed cost-effective.

7) Initiate lipid management therapy with the lowest-cost statin.5,11

A 28-day course of a branded statin is more costly than a generic statin, despite similar clinical efficacy.11 The number of prescriptions for statins is rising by around 20% per year. Current expenditure on statins is around £500 million per year.5 Starting patients on simvastatin 40mg6 or another statin of similar efficacy and cost could result in savings.11

8) Initiate ACE inhibitor therapy with the lowest-cost generic version.5,11

There are generic versions available for some of the ACE inhibitors that are less costly than branded ACE inhibitors, but equally as effective.11

The volume of prescribing of ACEIs is increasing significantly. Expenditure in primary care in England on medications affecting the rennin-angiotensin system currently stands at over £400 million per year. Prescribing generic, rather than branded ACEIs can be more cost effective.

9) Use the least-costly dressing for foot ulceration in people with diabetes.12

An HTA published in 2009 found no evidence of any difference between N-A, Inadine and Aquacel dressings for the treatment of diabetic foot ulcers and concluded clinicians should select the most cost-effective and convenient producy.12

10) Provide access to specialist services to inpatients with diabetes for both emergency and planned care.13

Some 40% of inpatients with diabetes do not receive the interventions that specialist diabetes teams would consider necessary.14 Diabetes complications account for almost 20,000 emergency admissions per year at a cost in excess of £40m.15 The number of bed days in England for patients with secondary diagnosis of diabetes for 2006/07 represented 7.6% of admissions.16 The introduction of a specialist inpatient diabetes service can reduce excess bed days in people with diabetes by 30%.17

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Ten ways to enhance a diabetes pathway The figures at a glance

£2,679 Net cost saving per patient over 10 years receiving the DAFNE education programme

£35.2m The cost of prescribing blood glucose testing strips over the past five years – with no evidence to support self-monitoring in most people with type 2 diabetes

£40m The cost associated with emergency admissions resulting from diabetes complications