Insulin pump therapy or continuous subcutaneous insulin infusion (CSII) is a method of delivering insulin using a pager sized device which infuses insulin through a subcutaneous cannula at a variable rate depending on the patients’ blood glucose and dietary carbohydrate. As a result, it provides a degree of flexibility and control difficult to achieve with even multiple daily injections. This treatment has been around for nearly 25 years and even has its own NICE guidance (2008). There are two current criteria for CSII: – inability to gain appropriate control (A1c<69mmol/mol) or recurrent hypoglycaemia despite optimised injections. NICE guidance also describes the makeup of the specialist team required who initiate this therapy, specifically a consultant diabetologist, diabetes specialist nurse and dietician and the provision of structured education for the patients. However, despite the benefit of this treatment and comprehensive guidance, there has been concern that its provision is not as comprehensive as NICE intended. In view of this a national audit was performed in 2012 to accurately assess CSII utilisation.
The authors audited all trusts in the UK providing pump therapy. They covered 13,428 patients and revealed that 93% of centres did not have any barriers in obtaining funding for patients who fulfilled NICE criteria. However, the mean number of consultant programme activities was 0.96, mean whole time equivalent diabetes specialist nurse 0.62 and dietician 0.3 of which 39, 61 and 60% respectively were not formally funded.
Whilst pump funding was, surprisingly, not an issue and mean duration of therapy was 7 years, interestingly 20% of patients were initiated in the previous year indicating significant growth. However, nationally the prevalence of pumps was 6%, compared to NICE expectations of 15-20%. This falls well below that of other European countries (>15%) and the USA (40%). The authors felt that, despite adequate funding of equipment, there is a significant shortfall in health care professional time to deliver CSII with subsequent lack of training and provision of appropriate structured education. Perhaps the transfer of routine diabetes management into primary care will free up specialist teams to provide this type of specialist service.
Dr Mark Freeman