Cost Savings Make Case for CGM Roll-out for T1D in Pregnancy

Liam Davenport

March 08, 2019

LIVERPOOL — The planned roll-out of real-time continuous glucose monitoring (CGM) to pregnant women with type 1 diabetes will save the NHS millions of pounds per year through reduced neonatal intensive care unit (NICU) admissions, as well as improve care, a cost-analysis of a landmark UK study shows.

For the analysis, presented at the Diabetes UK Professional Conference, the researchers extracted complication data from the CONCEPTT trial, which had shown that the use of CGM during pregnancy in women with type 1 diabetes improved birth outcomes compared with traditional finger-prick tests.

CGM Advantages

As reported by Medscape Medical News at the time, women using CGM had lower HbA1c levels and spent 100 minutes more time per day in the recommended glycaemic target range than those using intermittent capillary glucose monitoring.

Moreover, compared with traditional testing, CGM was associated with a significantly reduced risk of large-for-gestational-age babies, admission to NICU, and the need for intravenous dextrose for neonatal hypoglycemia.

Now, the researchers combined data from CONCEPTT with cost data from NHS England and the manufacturer to determine the budgetary impact of the use of real-time CGM.

They found that, when applied to a cohort of more than 1400 women derived from the 2016 National Pregnancy in Diabetes Audit, the use of CGM would have saved more than £9.5 million.

This was largely driven by marked reductions with CGM over finger prick monitoring in both the likelihood of admission to NICU, which would be cut by more than a third, and the length of time spent on the unit, which would drop by over a quarter.

Prof Helen Murphy, clinical professor in medicine (diabetes and antenatal care), Norwich Medical School, University of East Anglia, who led the researchers, said the findings show that "the routine use of CGM can result in substantial cost savings to the NHS, and hence it has now been recommended to be included in the 10-year NHS Long Term Plan".

Addressing the audience, she added: "We look forward to working with you in rolling this out and making it happen from 2020/2021."

Prof Anne Dornhorst, professor of practice, Centre for Endocrinology, Imperial College London, who co-chaired the session, said the results of CONCEPTT and this analysis are "going to change our management of type 1 diabetes in pregnancy and a lot of women will be thanking you".

In reply, Prof Murphy said that there will be a lot of women who will be "frustrated at the alarms, frustrated at blood sugar control and I think a lot of us will have a lot to learn as women start using it more".

However, she continued: "The key thing for me is that every little bit helps. Women don’t have to get to perfect control, but every little bit they get is worth having and will reduce the risks for their babies."

While acknowledging the "significant cost savings to the NHS" with CGM, Dan Howarth, head of care at Diabetes UK, said in a news release: "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."

"So 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."

Healthcare Budget Impact Model

To investigate further, the researchers used CONCEPTT and other published data to develop a model of the complications likely to be experienced by pregnant women with type 1 diabetes using real-time CGM versus traditional finger prick monitoring.

They then constructed a healthcare budget impact model of real-time CGM during pregnancy from NHS England and manufacturer cost data, assuming that it would be used for 28 weeks, between 10 and 38 weeks gestation.

In addition, they determined the average cost of a 24-hour NICU stay, as well as post-natal ward costs, the incremental cost of delivery with complications, and the unit cost of glucose test strips.

Finally, the researchers gathered epidemiological data from the 2016 National Pregnancy in Diabetes Audit, modelling a cohort of 1441 pregnant women with type 1 diabetes.

Extrapolating from CONCEPTT and assuming the same clinical outcomes, they calculated that NICU admissions would be needed in 27% of women using CGM compared with 43% of those using finger prick monitoring.

Moreover, the mean stay on the NICU would be shorter with CGM, at 6.6 days compared with 9.1 days for women using finger prick monitoring.

Prof Murphy noted, however, that fewer admissions to the NICU with CGM versus self-monitoring would lead to more postnatal ward admissions, at 57% and 42%, respectively.

The duration of stay on the postnatal ward if it were proceeded by a NICU stay would again be shorter for the CGM group, at 4.1 days versus 6.4 days for finger prick monitoring, although it would be the same for postnatal ward stays without prior NICU care, at 3 days in each group. 

Finally, the team calculated that the rate of pre-eclampsia for women using CGM during pregnancy would be half that in those using finger prick monitoring, at 9% versus 18%.

Budget Impact

Prof Murphy showed that the budget impact of those differences in outcomes would be reflected in an overall healthcare cost for the 1441 women using self-monitoring of £23,725,648 versus £14,165,187 for CGM.

This indicates that, across the cohort, using real-time CGM for an average of 28 weeks by pregnant women with type 1 diabetes would lead to a potential overall cost-saving of £9,560,461.

Prof Murphy pointed out that the drivers of this cost saving were, overwhelmingly, the reductions in the number and length of NICU admissions, which more than compensated for the increased cost associated with the device.

She added that the team had performed "a range of sensitivity analyses looking at the frequency of finger stick monitoring, the number of days that babies spent on the postnatal ward, and the CGM remained cost-saving across all of those, albeit to a greater or lesser extent".

In the post-presentation discussion, it was pointed out that other units have calculated the cost of a 24-hour stay in NICU to be lower than the £3743 used in the current analysis.

Prof Murphy pointed out that they took that into account in their sensitivity analyses, calculating that, even at the lowest potential NICU cost of £2400, the use of CGM still led to cost savings across the cohort of £5,44,736.

Prof Dornhurst also asked whether the same cost savings would apply if CGM were rolled out to pregnant women with type 2 diabetes.

Prof Murphy replied: "We know that the rate of NICU admissions in the type 2 offspring is about half of that [in type 1 diabetes], so I think it would be possible for it to be cost neutral.

"Whether or not it would be cost saving, I don’t know."

Alicia Sale is health economist employed by Medtronic.

The study was sponsored by Medtronic.

Diabetes UK Professional Conference: Abstract A52/P361. Presented March 7.


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