Summary
The d-Nav Insulin Guidance Service is a technology-enabled managed service providing automated insulin dosage titration for patients using basal, premixed, and basal-bolus insulin regimens with and without carb counting. When implemented in a Trust in Northern Ireland mean HbA1c decreased and patient satisfaction was high. Meanwhile, cost effectiveness analysis demonstrates that d-Nav is cheaper than the current standard of care.
Results
A total of 96 patients completed phase 1 of the evaluation. The mean (± SD) HbA1c for active users decreased from 9.2 ± 1.4% (77 ± 15 mmol/mol) at baseline to 7.8 ± 1.2% (62 ± 13 mmol/mol) at the 3 - 5 month clinic visit and to 7.5 ± 1.2% (58 ± 13 mmol/mol) at the 6 - 12 month clinic visit. In patients for whom paired data were available, the decreases were statistically signifi cant at both post-baseline visits (both p<0.001). This represented an increase in patients achieving goal HbA1c from 13% at baseline to 39% at 3 – 5 months and 60% at 6 - 12 months. In phase two the cumulative HbA1c data for 270 patients showed that 85% achieved and maintained HbA1c at goal. After three months on the service patients' average HbA1c was 7.5 ± 1.2% (58 ± 13 mmol/mol) and after 9 months average HbA1c was 7.2 ± 1% (55 ± 11 mmol/mol). A phase 3 service rollout is currently underway with 561 patients using the service as of 31 May 2016. Only 18% of patients were achieving HbA1c ± 8% (64 mmol/mol) at baseline whereas 69% are achieving this target after a minimum of 3 months on the d-Nav Service. Based on UKPDS data a 1% reduction in HbA1c decreases risk of diabetes related death by 21%; risk of MI by 14%; risk of microvascular complications by 37% and risk of peripheral vascular disease by 43%. This clearly demonstrates the impact of the d-Nav insulin guidance service on patients, who experience a mean HbA1c reduction of 1.78% thereby reducing their risk of life changing complications and helping them remain healthy. Data from phases one and two of the project showed the d-Nav service is cheaper than the standard of care. Health economic modelling carried out by the York Health Economic Consortium on the effect of improved glycaemic control on prevalence and healing rates of diabetes foot ulcers predicts that using the d-Nav Insulin Guidance Service for all patients using insulin in Northern Ireland (approx. 12,636) would save the healthcare system £12.7m over three years. Applying this to the entire UK (600,110 insulin users) could save the NHS £600m over three years.
Challenge
Achieving good glycaemic control in type 2 Diabetes is important to prevent mortality and costly complications. Unfortunately achieving good glycaemic control in people with type 2 Diabetes is a worldwide challenge. Standard UK clinical practice is to start with dietary and lifestyle modification, progressing to antidiabetic drug therapy when glycaemic control is no longer achieved and intensifying drug therapy if the patient remains above target. Yet even when using insulin many patients still fail to achieve glycaemic control targets - many patients are only seen for dosage adjustment every six months.
Objectives
To improve glycaemic control using the technology-enabled d-Nav insulin guidance service for patients with type 2 diabetes using insulin in South Eastern HSC Trust. To show that d-Nav is more cost effective than the current standard of care, making better use of insulin and reducing use of concomitant medications.
Solution
The d-Nav Insulin Guidance Service is a technology-enabled managed service which simplifies insulin management by automatically providing dose-by-dose and weekly insulin titration to help patients achieve their glycaemic control targets. The patient uses d-Nav to receive dose recommendations before each injection based on their blood sugar readings. The technology to analyse the readings is built into the device which automatically titrates insulin dosage and then recommends each insulin dose on the screen. It currently supports patients using four insulin regimens – basal only, premixed, and basal bolus with or without carb counting. The new service was phased in to initially test the hypothesis that it would improve glycaemic control and also to allow the clinical team to grow in experience and confidence with the service. This began with an initial pilot evaluation involving 96 patients, data from which informed a business case supported by the commissioners to extend the service to 270 patients. Further data was collected to enable service roll out to 700 users across the Trust including development of a GP Direct Referral Pathway to embed the service in the community. Patients enrolled on the service were asked to use d-Nav before every insulin injection and any time they suspected the occurrence of hypoglycaemia. They were then asked to follow the insulin dose recommendation made by d-Nav or use the device to record the dose taken if not following the recommendation. Patients received telephone support from specialist nurses according and were followed up at three-monthly face-to-face clinic visits where an HbA1c was measured and data on blood glucose measurements and insulin dosage were downloaded from the device.
Learnings
Results from the patient survey show they are highly satisfied with the d-Nav service and the improvements in glycaemic control they have achieved. They also report feeling empowered by achieving glycaemic control and this has led to improvements in lifestyle and diet for some patients. The d-Nav service shows short term cash savings in lancets, test strips and concomitant antidiabetic drugs and efficiency gains through reduced Consultant and DSN visits, with medium and long term savings through reduced complication rates.
Evaluation
Prescribing data was used to demonstrate the real cash savings in lancets, test strips and medications while Trust data was used to demonstrate the efficiency gains in Consultant and DSN visits. HbA1c data was collected prospectively to demonstrate improvements in glycaemic control compared with standard of care. In the Service Expansion phase, data was gathered to demonstrate sustainability of improvements in glycaemic control and cost savings as the service was scaled up.
