Diabetes Technology Network releases pump pathway
An insulin pump pathway has been developed to help increase uptake across the UK.
The guidance has been produced by the Diabetes Technology Network (DTN) and includes:
- Definition of high-quality care
- Key skills
- A pump pathway
- Flow chart for commencing CSII remotely
It has been put together by Professor Pratik Choudhary, Dr Alistair Lumb, Dr Emma Wilmot, Geraldine Gallen, Sara Hartnell, Dr Iain Cranston and Jackie Elliott on behalf of the DTN committee.
Continuous Subcutaneous Insulin Infusion (CSII) using insulin pumps have been shown to improve glucose control, reduce hypoglycaemia and improve the quality of life of people living with type 1 diabetes[ Pickup,2004] . NICE issued a TA in 2008 that made the following recommendations [NICE, 2008]:
Continuous subcutaneous insulin infusion (CSII or ‘insulin pump’) therapy is recommended as a treatment option for adults and children 12 years and older with type 1 diabetes mellitus provided that:
- attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia. For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of lifeOR
- HbA1c levels have remained high (that is, at 8.5% [69 mmol/mol] or above) on MDI therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care.
Following initiation in adults and children 12 years and older, CSII therapy should only be continued if it results in a sustained improvement in glycaemic control, evidenced by a fall in HbA1c levels, or a sustained decrease in the rate of hypoglycaemic episodes. Appropriate targets for such improvements should be set by the responsible physician, in discussion with the person receiving the treatment or their carer.
NICE TA151 does not specify high level of care, but does clarify that trained specialist team should provide structured education programs and advice on diet, lifestyle and exercise for people using CSII
The document said: “The DTN has been made aware that in many places across the UK, this has been interpreted as the need to complete a face to face structured education course. While all of us at DTN strive towards widespread access and availability of high- quality structured education in flexible insulin therapy, we are aware of a number of challenges to this that prevent people with type 1 diabetes (PwT1D) from accessing insulin pump therapy.”
Current challenges in access to CSII:
- Lack of clarity in defining “high quality of care”
- Lack of access to accredited quality assured structured education such as DAFNE.
- Where courses are available, there is limited capacity. Analysis done by the London T1. Network found that even if all courses were completely filled, the capacity for DAFNE just about covers the numbers of people who will be newly diagnosed with Type 1 diabetes, leaving long waiting lists for others. The National Diabetes Audit report showed that 33.9% of services did not deliver approved structured education, and almost a fifth of people with diabetes who are referred wait longer than 6 months. [ NDA, 2018]
- Some PwT1D are unable to access the education that is available due to limited timings, work or childcare commitments, financial or social circumstances.
- Some teams only offer/prioritise education for those on a “pump pathway” without leaving adequate time to assess the effectiveness of self-management skills.
- Some PwT1D who have acquired skills in flexible insulin management – either self-taught or through follow-up visits over time are forced to wait to do structured education courses for a long time when they may not need to.
- Some centres do not leave adequate time between completing the course and starting insulin pump therapy to assess the impact of the course.
- Some centres only offer a limited choice of insulin pumps.
These challenges may be the reason why insulin pump uptake in the UK remains low compared to other western European counties, DTN said.