The Health Information and Quality Authority has published a rapid health technology assessment (HTA) on the use of continuous glucose monitoring (CGM) systems in adults with Type 1 diabetes. The HTA was requested by the Health Service Executive (HSE) in 2022.
The purpose of this document was to provide an overview of the evidence in relation to CGM systems and to inform decision-making by the HSE as to whether reimbursement for CGM systems in the Irish healthcare system should be extended to additional adult populations with Type 1 diabetes who may benefit from this technology.
People with Type 1 diabetes must deliver insulin from the onset of diabetes for the rest of their lives or until a cure for diabetes is found. Insulin is delivered subcutaneously – the majority of people with Type 1 diabetes take with Multiple Daily Injections (4-5 or more injections a day), and some use insulin pump therapy. To estimate the correct insulin doses and maintain glucose levels as close as possible to optimal ranges, and reduce the occurrence of diabetes-related complications both severe (i.e. severe hypoglycaemia) and long-term (e.g. heart disease or kidney disease), frequent daily glucose monitoring is crucial.
Traditionally, self-monitoring has been performed with a finger-prick test to get point-in-time information on current glucose levels. An alternative to this is to use a continuous glucose monitoring, or CGM, system. With these systems, a small disposable sensor is inserted by the user under the skin. The sensor frequently monitors glucose levels (every couple of minutes) with the readings either sent directly to a reader (rtCGM) or obtained by scanning the sensor (isCGM). The glucose levels are shown on a graph and provide contextual information (glucose level rising, falling or no change), which improves insulin dosing estimates. Real-time CGM (rtCGM) also provides alarms when the glucose levels are rising or falling out of the range. CGM systems are also a part of the automated insulin delivery systems (AID), which semi-automatically deliver insulin based on glucose levels. CGM in Ireland, is, however, mainly used by adults living with Type 1 diabetes who are injecting insulin, as they are the majority of Type 1 diabetes population.
The HIQA report reviewed existing evidence and found some evidence that the use of CGM led to improved average blood glucose levels for people with Type 1 diabetes compared with self-monitoring with a finger-prick test, particularly in relation to time in range, provided reductions in hypoglycaemia events and for some improved quality of life. According to the HIQA report, there are a number of CGM systems available which differ in price but have similar effectiveness. Currently, some CGM devices are less available than others in Ireland – the HSE has a managed access programme for one of these systems; however, the arrangements for accessing the other systems have differed.
Dr Conor Teljeur, HIQA’s Chief Scientist, said: “CGM is an alternative form of blood glucose monitoring currently used by over half of all adults with Type 1 diabetes in Ireland. Different routes to accessing CGM have meant that the more expensive systems have been easier to obtain. We are advising the HSE that a single managed access programme with clearly defined eligibility criteria would improve equity of access and could help to control costs.”
According to HIQA, annual HSE expenditure on CGM systems for adults with Type 1 diabetes increased from €0.9 million in 2016 to €30 million in 2022. Over 90% of the expenditure in 2022 related to the more expensive CGM systems as they have been more easily accessed by adults. The budget impact of providing access to CGM to all adults with Type 1 diabetes would be between €24.8 million and €84.8 million over five years, depending on which system is adopted.
Dr Teljeur added: “We have also advised that CGM should continue to be provided in the context of the existing model of care for people with Type 1 diabetes which includes oversight by specialist diabetes services and empowerment of individuals through access to structured diabetes self-management education.”
Dr Kate Gajewska, Diabetes Ireland Advocacy & Research Manager in welcoming the findings said “We would urge the Minister for Health to accept the findings of the HTA report and act immediately to remove current restrictions on access to all CGM systems and make them accessible for all adults with Type 1 diabetes. We also welcome the suggestion to develop a single managed access programme that would provide a level playing field for all CGM reimbursement applications to the HSE and ensure equity of access for all. Diabetes technology not only improves diabetes management, but also the quality of life of people with diabetes. Investing in better management tools now, means less spending on diabetes complications and associated hospitalisations in the future.”
Diabetes Ireland, alongside the HSE National Clinical Programme, has recently launched its Pre-Budget Submission 2024 and included a call for additional funding of €5m to enable more equitable access to continuous glucose monitoring (CGM) for people with Type 1 diabetes. Professor Derek O’Keeffe, National Clinical Programme for Diabetes Lead said before its launch: “In line with international best practice, the National Clinical Programme for Diabetes is requesting a broadening of the criteria for the provision of a form of CGM to all individuals living with Type 1 diabetes in Ireland. Bearing in mind that many people already use CGM in Ireland, securing €5 million by the Government in the Budget 2024 will facilitate more equitable access and reduce disparities for those living with Type 1 diabetes who have not availed of this technology yet, will help them improve their diabetes management, outcomes and quality of life.”
For more information about our Pre-Budget Submission 2024 and how to support our request for extra funding to widen access to CGM click here.