Inter-Regional Center for Automated Insulin in Diabetes (CIRDIA) and Hospital-Based Approaches to Closed-Loop Therapy in Type 1 Diabetes: Cost-Effectiveness Analysis.

Background: Closed-loop insulin delivery is the new standard of care for patients with type 1 diabetes (T1D). However, in France, its implementation remains predominantly hospital based. Expanding access to this treatment through alternative care models looks essential. Objective: This study (cost-effectiveness analysis) compares 2 care models for people with T1D implementing a closed-loop system in France: outpatient care in the Inter-Regional Center for Automated Insulin in Diabetes (CIRDIA) and inpatient care. Methods: We conducted a cost-effectiveness analysis using retrospective observational data from individuals with T1D aged 16 years and older from the implementation of the closed loop to a 12-month follow-up either in the CIRDIA (CIRDIA group) or in a hospital center setting (hospital center [HC] group). The cost analyses were based on patient records and public databases: the French Medical Information Systems Program and the French General Nomenclature of Professional Acts. Closed-loop efficacy was assessed using a time in range (TIR) of 70 to 180 mg/dL, and closed-loop safety was assessed using the glycemia risk index (GRI), a single indicator that represents the risk of hypoglycemia or hyperglycemia and ranges from 0 (minimal risk) to 100 (maximal risk). Results: A total of 201 patients were included: 128 in the CIRDIA group and 73 in the HC group. The mean (SD) age was 43 (14) years and 46 (15) years, respectively. Mean (SD) baseline TIR was 52.9% (16%) in the CIRDIA group versus 65.9% (15.1%) in the HC group (P<.001), whereas mean (SD) baseline GRI was 56.4 (21) in the CIRDIA group versus 37.8 (19.8) in the HC group (P<.001). After 12 months, both groups achieved similar efficacy and safety outcomes with a mean (SD) TIR at 72.7% (11.6%) in the CIRDIA group versus 71.9% (10.5%) in the HC group, and a mean GRI at 30.1 (14.1) versus 30.3 (13), respectively. There were no significant between-group differences (P=.60 for TIR; P=.91 for GRI). However, the CIRDIA was associated with significantly lower management costs with a mean cost of €8373.12 (SD €427.30; €1=US $1.10 at the time of the study) per patient in the CIRDIA group versus €8814.32 (SD €192) per patient in the HC group (P<.001). The estimated saving was €626 per percentage point of increase in TIR and €2011 per point of reduction in GRI, indicating that the HC closed-loop initiation was dominated by the CIRDIA. The CIRDIA was less costly than HC in 8600 (86%) out of 10,000 simulations in a probabilistic sensitivity analysis. Conclusions: These findings suggest the potential of the CIRDIA to represent a viable alternative organizational model for closed-loop initiation in France, achieving comparable effectiveness at lower cost in our population. Further research with longer follow-up is warranted. From a policy perspective, the resources saved could be at least partly reallocated to support out-of-hospital closed-loop initiation centers.