title: Resource use and outcomes associated with initiation of injectable therapies for patients with type 2 diabetes mellitus.
abstract: BACKGROUND
  Management of type 2 diabetes mellitus (T2DM) often requires intervention with oral and injectable therapies. Across National Health Service (NHS) England, injectable therapies may be initiated in secondary, intermediate or primary care. We wished to understand resource utilization, pathways of care, clinical outcomes, and experience of patients with T2DM initiated on injectable therapies.
  
  
  METHODS
  We conducted three service evaluations of initiation of injectable therapies (glucagon-like peptide-1 receptor agonists (GLP-1 RAs) or basal insulin) for T2DM in primary, secondary and intermediate care. Evaluations included retrospective review of medical records and service administration; prospective evaluation of NHS staff time on each episode of patient contact during a 3-month initiation period; patient-experience survey for those attending for initiation. Data from each evaluation were analysed separately and results stratified by therapy type.
  
  
  RESULTS
  A total of 133 patients were included across all settings; 54 were basal-insulin initiations. After initiation, the mean HbA1c level fell for both types of therapies, and weight increased for patients on basal insulin yet fell for patients on GLP-1 RA. The mean cost of staff time per patient per initiation was: £43.81 for GLP-1 RA in primary care; £243.49 for GLP-1 RA and £473.63 for basal insulin in intermediate care; £518.99 for GLP-1 RA and £571.11 for basal insulin in secondary care. Patient-reported questionnaires were completed by 20 patients, suggesting that patients found it easy to speak to the diabetes team, had opportunities to discuss concerns, and felt that these concerns were addressed adequately.
  
  
  CONCLUSIONS
  All three services achieved a reduction in HbA1c level after initiation. Patterns of weight gain with basal insulin and weight loss with GLP-1 RA were as expected. Primary care was less resource-intensive and costly, and was driven by lower staff costs and fewer clinic visits.
authors: Whitstable Health Centre, Harbour Street, Whitstable, CT5 1BZ, UK;
authors: Richard
authors: R
authors: Brice
authors: Adult Diabetes Service, Diabetes Care Centre, Craylands Clinic, Craylands, Basildon, SS14 3RR, UK;
authors: Sharon
authors: S
authors: Shelley
authors: Bassetlaw District General Hospital, Kilton Hill, Worksop, Nottinghamshire, S1 0BD, UK;
authors: Pankaj
authors: P
authors: Chaturvedi
authors: Novo Nordisk, Crawley, West Sussex RH6 0PA, UK;
authors: Divina
authors: D
authors: Glah
authors: Novo Nordisk, Crawley, West Sussex RH6 0PA, UK;
authors: Donna
authors: D
authors: Ashley
authors: pH Associates, Derwent house, Dedmere Road, Marlow, SL7 1PG, UK.
authors: Monica
authors: M
authors: Hadi
keywords: diabetes; injectable therapies; intermediate care; outcomes; patient pathway; primary care; resource use; secondary care; service evaluation
references: Diabet Med. 2012 Jul;29(7):855-62
references: 22537247
references: Diabetes Care. 2013 Apr;36(4):1033-46
references: 23468086
references: Pharmacotherapy. 2014 Nov;34(11):1174-86
references: 25382096
references: Diabet Med. 2012 Aug;29(8):e191-8
references: 22507537
references: Diabetologia. 2009 Oct;52(10):2046-55
references: 19688338
references: BMJ Open. 2013 Apr 30;3(4):null
references: 23633415
references: Med Clin North Am. 2015 Jan;99(1):157-86
references: 25456649
references: Clin Ther. 2007 Mar;29(3):478-87
references: 17577469
references: Diabetes Obes Metab. 2007 Nov;9(6):799-812
references: 17924864