A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial
Authors: Heller Simon , White David , Lee Ellen , Lawton Julia , Pollard Daniel , Waugh Norman , Amiel Stephanie , Barnard Katharine , Beckwith Anita , Brennan Alan , Campbell Michael , Cooper Cindy , Dimairo Munyaradzi , Dixon Simon , Elliott Jackie , Evans Mark , Green Fiona , Hackney Gemma , Hammond Peter , Hallowell Nina , Jaap Alan , Kennon Brian , Kirkham Jackie , Lindsay Robert , Mansell Peter , Papaioannou Diana , Rankin David , Royle Pamela , Smithson W Henry , Taylor Carolin 
Published: April 2017

Background

Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment.

Objective

To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy.

Design

Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI.

Setting

Eight secondary care diabetes centres in the UK.

Participants

Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps.

Interventions

Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm®VeoTM(Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK).

Main outcome measures

Primary outcome – change in glycated haemoglobin (HbA1c) at 2 years in participants whose baseline HbA1cwas ≥ 7.5% (58 mmol/mol). Key secondary outcome – proportion of participants with HbA1c≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months – moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness.

Results

We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA1cof ≥ 7.5%. HbA1cand severe hypoglycaemia improved in both groups. The drop in HbA1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA1cchange at 2 years, at which the baseline HbA1cwas ≥ 7.5%, was –0.24% [95% confidence interval (CI) –0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of –0.36% (95% CI –0.64% to –0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews.

Limitation

Blinding of pump therapy was not possible, although an objective primary outcome was used.

Conclusion

Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM.

Research priority

To understand why few patients achieve a HbA1cof < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries.

Trial registration

Current Controlled Trials ISRCTN61215213.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 20. See the NIHR Journals Library website for further project information.