Find out which sin is considered by a leading international expert to be the most deadly.
Speaking at a session this afternoon on the vices and virtues of diabetes technology internationally renowned expert Professor John Pickup from Kings College London in the UK said diabetes technologies were making an important contribution to the improved care of people with diabetes.
However, not everybody was enthusiastic about diabetes technology and many distinguished healthcare professionals were suffering from the ‘technology blues’.
According to Professor Pickup the issues with insulin pumps and continuous glucose monitoring (CGM) were a very slow uptake into clinical practice, variable and limited availability, and continued debate about their efficacy.
“We’re uncertain about the role of diabetes technology in routine clinical practice,” he told delegates.
As new diabetes technologies emerged it was important to learn lessons from the problems we’ve had in the past, Professor Pickup stressed.
“I want to give you seven deadly sins of diabetes technology and how to avoid them,” he said.
The seven deadly sins according to Professor Pickup
1. The wrong patients are tested
Don’t study the wrong patients with the wrong trials. The mean is meaningless, and short term trials are also usually meaningless. Don’t include trials in a meta-anlysis that include obsolete technology (for example, first generation pumps). Don’t study those who are well controlled, don’t exclude patients from trials those most likely to benefit.
2. Short not long-term evaluation
If you look at the changes in HbA1c on switching from MDI to insulin pump therapy in the short term everything looks ‘reasonably terrific’, Professor Pickup told delegates. “But we need to consider long term outcomes on HbA1c and also clinical outcomes like macro and microvascular disease, mortality and quality of life,” he said.
3. Poor surveillance of reliability
In spite of the increasing sophistication of insulin pump therapy reliability is not completely sorted out at the moment, Professor Pickup said. This illustrated that continued post market surveillance of new technology was really needed.
4. Considering it value for money for everyone
There have been 11 cost effectiveness studies in 8 different countries comparing the health economics of pump therapy with MDI in type 1 diabetes, Professor Pickup noted.
Pump therapy was considered to be cost effective in all of the studies in all of the countries. However Professor Pickup said the greatest reduction in risk and cost was associated with people living with diabetes who have the worst control at baseline. “That’s the reason why in international and national guidelines guidance on pump therapy is very much related to the degree of hypoglycaemia after best attempts with injection therapy,” he said. “It’s not affordable for all patients”.
5. Not asking patients what they think
Professor Pickup recently conducted an online survey of UK patients narratives around using CGM. They said things like, ‘the crazy number of alarms that really bother her’ or ‘the sticky on the sensor often wouldn’t stick to my skin’. But then, ‘Overwhelmingly positive I think the low suspend feature has saved my daughter’s life on at least two or three occasions… I would never be without it’.”
6. Access to technology not being equitable
This is a major deadly sin, according to Professor Pickup. “Even if you say a quarter of patients aren’t suitable for pumps, or have declined therapy, at least 20 percent of patients ought to be offered a trial of insulin pump therapy on clinical grounds alone,” he said. However the uptake rates in different countries showed a ‘tremendous variation’ with the UK and Australia falling below that 20 percent level. “There’s a lot of work that needs to be done in increasing uptake,” he told delegates.
7. Best practice not agreed
Professor Pickup noted that CGM in Europe had been very slow and partial in its uptake. “Very often national health services and insurance schemes have been very slow to reimburse and reluctant to reimburse CGM,” he said. “There are few evidence based guidelines.”
What’s the solution?
With new diabetes technologies we need to consider testing in the correct patient groups and include long term evaluation and post marketing surveillance, Professor Pickup said.
“We need to consider carefully affordability, the patient’s view, equitable access to ensure guidelines are best practice”.
Much of this was now in place for CSII and CGM but it needed to be considered for the emerging technologies of the future.
“These technologies, I would put to you, should now have an agreed place and role in routine diabetes care,” he concluded.