PM is a 48-year-old woman with a 24-year history of type 1 diabetes. She had been on MDI for 15 years and on CSII for 7 years and was currently using a Paradigm® 712 insulin pump. She wished to be upgraded to a real-time insulin pump with continuous glucose sensing. Her HbA1c had been 12% on MDI but was 9% on CSII.
In the previous year she was diagnosed with diffuse cardiovascular disease with a 95% occlusion of the right coronary artery and a 65% occlusion of the left coronary artery. She required an angioplasty and TAXUS® drug-eluting stent to the right coronary artery. She also suffered from severe pre-proliferative retinopathy and maculopathy. Despite steadily increasing insulin dosage, she continued to have erratic glycaemic control and her HbA1c was stuck at 9%. She attended cardiac rehabilitation following her stent procedure but experienced frequent episodes of hypoglycaemia. She needed to intensify her control, exercise regularly and follow a low fat, calorie-controlled diet to aid with weight loss in order to reduce her risk of future cardiac incident or further intervention.
Why a real-time insulin pump with continuous glucose sensing?
PM felt that she was already doing her best to achieve tight control, but that it simply was not good enough. Her recurrent hypoglycaemia during exercise was acting as a barrier to carrying out the exercise she needed to improve her cardiac health. She also struggled with weight loss due to over correction during exercise-induced hypoglycaemia. Morning blood glucose levels were very variable despite frequent monitoring. It was felt that using the Paradigm® REAL-Time plus glucose sensors would enable her to tighten control through identifying trends as well as being able to act on falling blood glucose levels before she became hypoglycaemic.
Presenting the case for funding
Obtaining unlimited funding for pumps, consumables and glucose sensing is not always easy and across the country there have been variable levels of success. To ensure the funding required for the patient was obtained, four steps illustrated in Figure 1 were used.
Ultimately, the case for funding must be constructed so that there is no choice but to fund. Although it is best to adhere to the criteria laid down in NICE guidance (NICE, 2003), the one absolute requirement for funding is the opinion of the clinician. If possible, it is always best to get the patient to send the letter and supporting information to the PCT, as this has a more direct impact on the PCT panel members.
The ideal letter should look like the one shown in Box 1, where actual sections from the successful application are used to illustrate general principles.
In this instance, the patient did improve her control and has benefited from improvement in her retinopathy, which has been downgraded from severe to moderate with no maculopathy present.
There is one crucial take home message here: If you want to ensure funding for CSII (with or without glucose sensing) then make sure you have thought of, addressed and answered any potential questions that might prevent funding. You should leave them with only one choice – to fund.