Glucose Monitoring

Health Technology Assessment Committee Recommendations

1. As the current evidence suggests glucose monitoring technologies, including continuous glucose monitors, flash glucose monitors, and hybrid closed loop insulin delivery systems, provide no additional clinical benefits compared to fingerprick blood glucose tests but provide non-clinical benefits such as added comfort, convenience, and flexibility in diabetes management, HTAC recommends funding for flash glucose monitors, the most cost-effective option assessed.
2. HTAC recommends funding for flash glucose monitors be provided based on functional, not clinical, need. The Ministry of Health should consult relevant stakeholders to define eligible populations that may or may not include children, adults with some level of either cognitive and/or physical disability, and adults whose occupation makes fingerpricking challenging.
3. HTAC recommends reviewing glucose monitoring technologies again when compelling new evidence of their clinical benefits becomes available.

Health Technology Assessment Committee Findings

1. A systematic review and a series of network meta-analyses were conducted on the comparative clinical effectiveness of fingerprick glucose tests, continuous glucose monitors, flash glucose monitors, and hybrid insulin delivery systems for the management of insulin-dependent diabetes. For children and adults with type 1 diabetes, no significant differences were found between glucose monitoring methods for HbA1c or number of hypoglycemic events requiring assistance. Due to limited evidence, no conclusions about efficacy could be drawn for type 2 diabetes and for type 1 diabetes in a pregnant population.
2. Some significant differences were found for time-in-range in both adults and children with type 1 diabetes. However, based on a systematic review of the validity of time-in-range, the literature to date suggests time-in-range should not be considered a validated surrogate for clinical outcomes and differences should be interpreted cautiously.
3. Health professionals interviewed felt the major advantage of the glucose monitoring devices was the quality of the information available to both the patient and their health care provider, increasing the understanding of what is happening with patients’ blood glucose levels and leading to improvements in the percentage of time patients spend in their target blood glucose range, HbA1c levels, and the number of serious hypoglycemia events.
4. Patients found continuous glucose monitors to be an effective tool in managing their glucose levels. Benefits noted include increased comfort in not having to perform multiple fingerpricks a day, improvements in sleep, and increased confidence and reassurance to make informed life decisions such as vacation and exercise.
5. No de novo cost-effectiveness analysis was performed because no difference in HbA1C or number of hypoglycemic events requiring assistance was identified in the clinical effectiveness review. An economic analysis by Health Quality Ontario found continuous glucose monitors were not cost-effective compared to usual care (i.e., self-monitoring of blood glucose using a finger-prick and a blood glucose meter) at common willingness-to-pay thresholds; incremental cost-effectiveness ratios (ICER) ranged from $592,206 to $1,108,812 per quality adjusted life-year (QALY), suggesting that any difference in QALYs is minimal.
6. Budget impact analysis suggests cost outcomes are sensitive to size of the population eligible for public funding of glucose monitors, the costs of the glucose monitors, and the size of the predicted market share of each glucose monitoring technology.