Research Paper
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Burdened No Longer: How Continuous Glucose Monitoring is Revolutionary in Diabetes Care
and Why British Columbia Should Fund It
Abstract
This paper discusses what Continuous Glucose Monitoring (CGM) technology is, and
draws on recent scientific research to explain why it is more effective for managing blood
glucose levels and preventing adverse health outcomes in patients with type 1 diabetes than other
methods. It further examines how, despite the health benefits associated with CGM use, the
technology has not yet seen widespread use in Canada due to the high out-of-pocket costs for
patients. Thus, this paper asserts that the British Columbia Ministry of Health should begin
providing public funding for CGM devices to ensure that all type 1 diabetics are able to access
this revolutionary technology and manage their health more effectively.
Figure 1 (left): Woman wearing a CGM sensor (Juvenile Diabetes Research Foundation, 2019) Figure 2 (right): CGM sensor, insulin pump and smartphone with glucose data (Diabetes Canada, 2018)
Context
Type 1 diabetes is a chronic, autoimmune condition characterized by the body’s inability
to produce insulin. Without insulin, a person’s cells cannot perform the metabolic processes
necessary for life, and so people living with diabetes follow intensive treatment regimens of
injecting insulin and monitoring blood glucose in order to maintain their health. Though the
management of this condition places a significant burden on the patient, recent developments in
technology have begun to provide more effective and less laborious methods of regulating blood
glucose. One of these technologies, Continuous Glucose Monitoring (CGM) has demonstrated
promising benefits for alleviating the medical burdens of type 1 diabetes by reducing the
incidence of extreme hyperglycemia and hypoglycemia (Diabetes Canada, 2018). CGM involves
the insertion of a disposable electrochemical sensor into the skin, which continuously measures
the glucose levels in subcutaneous tissue, and then wirelessly transmits this data to the user’s
insulin pump or smartphone (Vettoretti & Facchinetti, 2019). However, for many people living
with type 1 diabetes in Canada, CGM is a potentially life-saving technology that remains out of
reach due to high costs (Juvenile Diabetes Research Foundation, 2019).
The inaccessibility of CGM technology represents a significant problem, since studies
show that regulation of blood glucose levels using the conventional method of self-monitoring
blood glucose (SMBG), which requires collecting small blood samples from the fingers six to
eight times daily, is demonstrably less effective (Diabetes Canada, 2018). Indeed, as shown in
figure 3, CGM use is associated with lower hemoglobin A1c (HbA1c) levels, which is the
standard metric used to assess a patient’s blood glucose regulation over a three month period
(Senn, Fischli, Slahor, Schelbert, & Henzen, 2019). This is due in part to the fact that the blood
glucose data attained through SMBG only offers information from individual points in time,
whereas CGM allows the patient to make more effective treatment decisions based on 24-hour
data on their blood glucose and its trends. Considering how long-term elevated HbA1c levels can
lead to diabetes-related complications such as kidney failure, neuropathy and amputation, the
importance of utilizing technologies such as CGM to avoid such outcomes becomes evident.
Figure 3: The impact of CGM use on blood glucose control through trends in HbA1c during a 6-month study (Giani, Snelgrove, Volkening, & Laffel, 2016).
Furthermore, CGM plays a crucial role in the safety of people with type 1 diabetes, as it
provides alerts when blood glucose is too high or too low. This technology can prevent
life-threatening emergencies due to high or low blood glucose by informing the user when there
is a problem and giving them the opportunity to act before serious health problems, such as
seizures, diabetic coma, or ketoacidosis, arise. According to Diabetes Canada, CGM use is
especially effective for type 1 diabetics who experience frequent episodes of hypoglycemia, and
is associated with a decrease in hospitalizations for those who use it (2018).
Finally, a 2019 study seeking to understand the benefits and limitations of CGM use
found that while CGM is generally seen as favourable by type 1 diabetics, one of the primary
reasons for discontinuing the treatment method was the high associated cost (Sørgård, Iversen, &
Mårtensson, 2019). As there is no national funding for CGM in Canada (Graham, 2017), type 1
diabetics without specific private health insurance must pay out-of-pocket for the cost of the
sensors, which ranges from $3000 to $6000 annually (Diabetes Canada, 2018). However, the
study by Sørgård, Iversen, and Mårtensson ascertained through interviews that many of the
diabetics who discontinued their use of CGM would resume using the technology if the cost
barrier were to be eliminated (2019). Thus, it can be concluded that the key to implementing
more widespread use of CGM among type 1 diabetics, and reaping the health benefits it
provides, could be achieved by removing the barrier of cost.
Recommendation
In light of the evidence for how CGM use improves health outcomes, and in accordance
with the recommendations of Diabetes Canada (2018), it is imperative that the British Columbia
Ministry of Health begins providing public funding for the use of CGM by people with type 1
diabetes. All costs associated with CGM should be covered under the province’s health insurance
in order to ensure that every type 1 diabetic in British Columbia can access this potentially
life-saving technology.
Though some may argue that providing this coverage would constitute an increase in
healthcare spending that the province cannot afford, there is evidence to indicate that this policy
would instead be cost-effective. One study tracking the public costs of pregnancy and delivery
for 1441 diabetic women found that the overall costs for the women regulating their glucose
using CGM was lower than for those using SMBG (Murphy, Feig, Sanchez, de Portu, & Sale,
2019). As illustrated in Figure 4, although the immediate costs of CGM are higher than SMBG,
this cost is offset by the reduction in length and frequency of neonatal intensive care unit
admissions. Though this data pertains specifically to pregnant women using CGM, the same
principle may be extrapolated to infer that the cost of providing public funding for CGM would
be offset by the consequently reduced medical complications associated with poor blood glucose
regulation.
Figure 4: Healthcare costs of pregnant women with type 1 diabetes when using CGM compared to SMBG (Murphy, Feig, Sanchez, de Portu, & Sale, 2019).
Another benefit of instituting public funding of CGM would be the opportunity to use it
in conjunction with an insulin pump. CGM sensors now have the ability to communicate with
some insulin pumps in such a way that allows the pump to increase or decrease insulin dosage
based on blood glucose readings (Graham, 2017). While these so-called “closed-loop systems”
or “artificial pancreases” are still an emerging technology, many experts expect them to quickly
become the new standard of care as they are demonstrating even more positive effects on blood
glucose regulation than CGM or insulin pumps alone (Graham, 2017). Thus, if British Columbia
Ministry of Health was to provide CGM funding, it would simultaneously be paving the way for
even more advanced and effective diabetes management technology.
In conclusion, in order to improve care for type 1 diabetics across the province and
reduce healthcare costs associated with poor blood glucose regulation, the British Columbia
Ministry of Health must make CGM accessible through the provision of public funding.
According to an article in the BC Medical Journal, diabetes places a significant burden on the
province’s healthcare system, accounting for over 70% of non-traumatic limb amputations, and
prevalence of both type 1 and type 2 diabetes is expected to continue increasing (Ur, 2018). In
order to ensure that taxpayer money is being spent effectively and that our limited healthcare
resources are not being wasted on preventable hospitalization, it is essential that the province
ensures all diabetics can access the care they need – not just those wealthy enough to afford it.
As long as there remains no cure for type 1 diabetes, those living with the condition rely on the
regulation of blood glucose for their health and survival, and the investment in technologies like
CGM are what allow diabetics to live long, fulfilling lives.
List of Works Cited
Diabetes Canada. (2018). Continuous glucose monitoring [PDF file]. Retrieved from
https://www.diabetes.ca/DiabetesCanadaWebsite/media/Managing-My-Diabetes/Tools
and Resources/Continuous_Glucose_Monitoring_Advocacy_Pkg_4.pdf?ext=.pdf.
Giani, E., Snelgrove, R., Volkening, L. K., & Laffel, L. M. (2016). Continuous glucose
monitoring (CGM) adherence in youth with type 1 diabetes: Associations with
biomedical and psychosocial variables. Journal of Diabetes Science and Technology,
11(3), 476–483. doi: 10.1177/1932296816676280
Graham, C. (2017). Continuous glucose monitoring and global reimbursement: An update.
Diabetes Technology & Therapeutics, 19(S3). doi: 10.1089/dia.2017.0096
Juvenile Diabetes Research Foundation. (2019). Making continuous glucose monitoring
accessible to all. Retrieved from
https://www.jdrf.ca/blog/making-continuous-glucose-monitoring-accessible-to-all/.
Murphy, H. R., Feig, D. S., Sanchez, J. J., de Portu, S., & Sale, A. (2019). Modelling potential
cost savings from use of real-time continuous glucose monitoring in pregnant women
with Type 1 diabetes. Diabetic Medicine, 36(12), 1652–1658. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/31162713
Nicolucci, A., Rossi, M., Dostilio, D., Delbaere, A., Portu, S. D., & Roze, S. (2018).
Cost-effectiveness of sensor-augmented pump therapy in two different patient
populations with type 1 diabetes in Italy. Nutrition, Metabolism and Cardiovascular
Diseases, 28(7), 707–715. doi: 10.1016/j.numecd.2018.03.011
Senn, J.-D., Fischli, S., Slahor, L., Schelbert, S., & Henzen, C. (2019). Long-term effects of
initiating continuous subcutaneous insulin infusion (CSII) and continuous glucose
monitoring (CGM) in people with type 1 diabetes and unsatisfactory diabetes control.
Journal of Clinical Medicine, 8(3), 394. doi: 10.3390/jcm8030394
Sørgård, B., Iversen, M., & Mårtensson, J. (2019). Continuous glucose monitoring in adults with
type 1 diabetes: A balance between benefits and barriers: A critical incident study.
Journal of Clinical Nursing. Retrieved from
https://onlinelibrary.wiley.com/doi/epdf/10.1111/jocn.14911?referrer_access_token=q1k
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Ur, E. (2018). Diabetes in British Columbia: Starvation in the midst of plenty. BC Medical
Journal, 60(9), 436–438. Retrieved from
https://www.bcmj.org/editorials/guest-editorial-diabetes-british-columbia-starvation-mids
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Vettoretti, M., & Facchinetti, A. (2019). Combining continuous glucose monitoring and insulin
pumps to automatically tune the basal insulin infusion in diabetes therapy: a review.
BioMedical Engineering OnLine, 18(1). doi: 10.1186/s12938-019-0658-x
