CGM During Type 1 Diabetes Pregnancy Makes Substantial Cost Savings Over Fingerprick Testing

Becky McCall

June 18, 2019

SAN FRANCISCO - Continuous glucose monitoring (CGM) in pregnant women with type 1 diabetes saves £2500 per pregnancy and birth compared with a pregnancy using fingerprick testing, shows a cost effectiveness analysis of the CONCEPTT randomised controlled trial (RCT) data.

Presenting results of the analysis at this year’s  American Diabetes Association (ADA) 2019 Scientific Sessions , was principal investigator, Dr Helen Murphy, clinical professor in medicine (diabetes and antenatal care), Norwich Medical School, University of East Anglia.


Neonatal cost effectiveness calculations showed that the cost of providing standard care with CGM was less than that without. "For a publicly-funded healthcare system like the NHS, we cannot afford not to provide CGM during pregnancy in mothers with type 1 diabetes. It costs £2500 more not to provide CGM, because CGM is more effective [than capillary blood glucose monitoring]," Prof Murphy stressed. "It falls well within the NHS willingness to pay threshold with an incremental cost effectiveness ratio of minus £1500 from a newborn perspective."

The analysis was based on findings from the CONCEPTT trial. This trial looked at whether there was a benefit or not in terms of glycaemia in pregnant mothers with type 1 diabetes who used CGM compared with capillary glucose monitoring. The results showed that CGM improved newborn health outcomes compared with capillary monitoring of blood glucose.

In summary, and as reported by Medscape Medical News at the time, the CONCEPTT trial found that large for gestational age babies were observed in 53% and 69% of births in CGM versus control groups respectively. The proportion of neonatal intensive care unit (NICU) admissions for longer than 24 hours was 27% in the CGM arm versus 43% in the control arm (odds ratio: 0.48; p=0.0157).

"In this cost effectiveness analysis, we wanted to look at the cost implications of integrating CGM into standard antenatal diabetes care," said Murphy, explaining the reasons for the retrospective cost effectiveness evaluation.

Dr David McIntyre, director of obstetric care University of Queensland, Australia moderated the session.  "The CONCEPTT health economic analyses clearly show substantial clinical benefits for reasonable costs with the use of CGM during pregnancy," he remarked after seeing the data. "The maternal costs are modest for so-called first world health systems. Most impressively, the savings in neonatal health care costs, driven by reduced length of stay in neonatal intensive care settings, are substantial.  The remaining challenges revolve around how to equitably deliver this new best practice standard of care to women with type 1 diabetes, across a broad range of health care settings."

Decision Tree Models for Maternal and Neonates

The analysis was based on direct costs of antenatal care in each trial arm with and without CGM, plus the researchers asked whether there was a benefit in terms of maternal and neonatal outcomes including both adverse effects and patient-reported outcomes. "We estimated the cost effectiveness of CGM in addition to standard of care to determine the incremental cost effectiveness ratio (ICER)," Prof Murphy explained.

The primary outcome was neonatal quality adjusted life years (QALY), a generic measure of disease burden including both the quality and the quantity of life lived.

Prof Murphy shared some of the fundamental design features of the maternal decision tree model to aid the calculations. This model randomised pregnant women to capillary blood glucose monitoring or CGM, defined pregnancy as complicated or uncomplicated, the birth as live born or stillborn, at term or pre-term, and by caesarean section or vaginal delivery. Individual patient level data were used to determine the probabilities of these different outcomes. In terms of complications, the model incorporated findings on pre-eclampsia, diabetic ketoacidosis, and episodes of severe hypoglycaemia needing third party assistance.

For the neonatal decision-tree, outcomes included mothers randomised to care with or without CGM, births that were live born or stillborn, at term or pre-term, and admissions to the post-natal ward or the NICU. Probabilities were again calculated for each outcome.

In terms of healthcare resource utilisation, the cost of standard antenatal care for a woman with type 1 diabetes (with capillary monitoring of blood glucose) was estimated at around £6500. The direct cost of instituting CGM from approximately 10 weeks of gestation until delivery was £1700, assuming each sensor costs £52 (thirty-three sensors across pregnancy). In addition, the costs of diabetes nurse specialists and dieticians were included, so the total additional costs of implementing CGM throughout pregnancy was approximately £2050. Maternal pregnancy complications and adverse events were also costed, for example, a normal delivery including inpatient hospital stay costs £2900 compared with £4500 for a caesarean delivery.
Preterm deliveries cost more than term ones, and a night in the NICU costs a lot more than a night in the postnatal ward. The mean cost of NICU admission was £1890 per day, which is approximately twice that of a night in the postnatal ward. The mean duration of NICU care when CGM was used compared with capillary monitoring of blood glucose alone was 6.6 vs. 9.1 days, respectively. 

Pre-term deliveries cost more than term ones, and a night in the NICU costs a lot more than a night in the post-natal ward. The mean cost of NICU was £1890 per day, which is approximately twice that of a night in the post-natal ward. The mean duration of NICU care when CGM was used with capillary monitoring of blood glucose alone was 6.6 vs. 9.1 days, respectively.

"In terms of maternal cost-effectiveness, there is an extra cost of £330 for providing antenatal care with CGM, including extra visits and support for CGM use; it was more effective," Murphy pointed out. "The maternal ICER came out at £5500 per QALY, which is considerably less than the National Institute for Health and Care Excellence (NICE) willingness to pay threshold that typically lies between £20,000-£30,000 per QALY. So CGM overall costs fall well within these thresholds."

Regarding other pre-specified outcomes, the model remained robust if a patient started CGM earlier, or the proportion of CGM users to multiple dose insulin injection users was varied, and for different rates of maternal complications. 

Similar groups have now performed similar analyses using budget impact models both in the UK and Canada, and the results are consistently in the same direction, said Prof Murphy. In Canada, use of CGM equates to a 30% cost reduction, while in the UK it is approximately 40%.

On the basis of these data the long-term plan for the NHS will be to offer CGM to all pregnant women with type 1 diabetes next year.

Life-Changing Technology

Emily Burns, PhD, head of research communications at Diabetes UK commented on the data: "This research shows that making continuous glucose monitoring technology available to all women with type 1 diabetes during pregnancy could lead to significant cost savings for the NHS. Costs aside, CGM could offer a better way to help pregnant women with type 1 diabetes keep their blood glucose levels in a safe range, to keep both mother and baby healthy.

"We’re delighted that this life-changing technology could become more accessible in the future following the pledge made in the NHS long-term plan. Importantly, we would recommend that anyone with type 1 diabetes who is planning to get pregnant speak to their healthcare professional to get the help and support they need."

COI: Dr Murphy is on the advisory panel for Medtronic MiniMed, Inc..

Dr McIntyre has declared no conflicts of interest.

Presented at American Diabetes Association (ADA) 2019. June 10th 2019. Abstract 351-OR.


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